Your Questions

Q: Dr. Eppley, I came across your website and am very impressed with your blogs on cheek bone reduction and jawlione shaving surgery. I underwent zygoma and jaw shaving both a month ago and am very worried regarding my decision. I have some questions to ask you, which I hope you can help me.

1) Is facial sagging more common with my surgeries of both zygoma shaving and jaw shaving? Two years previously, I had buccal fat removal and facial liposuction. I am worried that this increased my chances of facial sagging?

2) The right side of my mouth is harder and more painful to open. Is this normal for slightly over one month post-op?

3) My facial swelling changes daily. Some days are more swollen and chubbier than other days. Is this normal?

4) Is zygoma and jaw shaving supposed to give a narrower face? A friend of mine is post op three months and she is chubby at the bottom cheeks. I have heard many stories of young girls having chubby bottom cheeks. Will it go away?

5) I have read that it takes 2 to 3 weeks for majority of the swelling to subside, I still feel I have a large amount of swelling. When would you say the majority of swelling will subside?

6) My doctor says that nothing can be fixed in the following months if facial sagging occurs on the cheeks, is this true?

A: In answer to your questions about cheek bone reduction and jawline shaving:

1) Soft tissue sagging is a more common problem with cheek bone reduction, not so much for jawline shaving. Having had a previous buccal lipectomy and facial liposuction did not increase your risk of soft tissue sagging with these procedures.

2) It would be perfectly normal to have stiffness and soreness of mouth opening and stiffness at the is early point after surgery. Expect full recovery to take 3 months.

3) Facial swelling is very cyclical after surgery due to positional changes of the face and resolving lymphedema.

4) You should not judge the final results from any facial bone surgery until a minimum of 3 and preferably 6 months after surgery. She may be chubby due to swelling and resolving lymphedema or may also perceptual enhanced lower facial fullness due to the now more narrow midface.

5) A few weeks after surgery is way too premature to expect most of the facial swelling to have gone away.

6) You need to wait 6 months to both judge the results and before embarking on any corrective procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about cheek bone reduction. I hope you can help me because I am very afraid. I had a zygoma reduction with the L-osteotomy. Now my cheeks are sagging. I can see it because of the swelling look around my mouth. Now my surgeon told me that he will do a midface lift and Medpor implants. Will that help or not? I am afraid because I read on some pages that it is very difficult to fix this problem. Is that right? Please help me, I don’t know what to do.

A: One of the well known risks of cheek bone reduction is loss of soft tissue support or cheek soft tissue sagging. Since the cheek bones act as attachments and support for the midface tissues, it is no surprise that in some cases with some cheek bone techniques that the cheek tissues may sag afterwards. It is not a universal complication of every cheek bone reduction but it definitely can occur. It is for this reason that I like to perform cheek tissue suspension at the same time as the cheek bone reduction.

Now that you have it, and I presume you are at least 3 or 6 months from the procedure, the treatment would be the reverse of what caused the problem. At the least the cheek soft tissues need to be elevated and this could be done through a combination temporal and intraoral suspension approach. While adding bony projection with a cheek implant can be an adjunctive procedure to a cheeklift, it seems counterproductive to add back cheek prominences when you went through the original operation to get rid of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting injectable fillers into my tear troughs (tear trough injections) but am very nervous about it. I have read numerous horror stories of significant bruising and clumps and irregularities in this area. What is the best way to inject the tear troughs and not have these problems?

A:  Injections for tear trough (nasojugal) effacement is the most technique sensitive of all injectable filler treatments of the face. I used to use a 1/2 inch 30 gauge needle and injected down to the level of the periosteum along the medial orbital rim. But the periosteum over the orbital rim is quite adherent and recent studies have shown that the periosteum and the retaining ligaments in this area are very difficult to elevate and are prone to bleeding and external bruising.

I have subsequently changed my tear trough filler technique to using a microcannula rather than a needle. Coming though the thicker cheek skin rather than the thinner eyelid skin, I enter the submuscular plane above the periosteum to inject. This approach puts the microcannula directly into the tear trough and has no risk of causing bleeding or bruising afterwards. This more superficial submuscular deposition of filler has improved my results dramatically. In addition, the entire tear trough can be filled from a single puncture in the upper cheek. The microcannula can reach the most medial part of the tear trough.

It is important when filling the tear trough to only use hyaluronic acid-based fillers to avoid clumping and to not overfill. Less is more when it comes to filling the tear troughs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting a rhinoplasty to reshape the tip of my nose. I have attached two pictures one picture being how my nose looks now (bulbous tip, very bulky in appearance) and a second picture of how I want it to be like. ( slim and straight) Would the result I hope to achieve be possible? What would need to be done to produce the desired result in the picture?

A: What you initially have is a bulbous tip that makes it fuller and stick above the rest of your otherwise straight dorsal line. This bulbous tip is composed of the union of the paired lower alar cartilages which are both wide (cephalic to caudal direction) and long. (anteroposterior direction) A tip rhinoplasty can reshape these cartilages by a cephalic trim, cartilage length reduction by medial footplate resection and dome narrowing by suture plication. Together these nasal tip changes are very likely to achieve the desired result that you have illustrated.

A tip rhinoplasty, what I call a Type 1 rhinoplasty, is done through an open approach and is  associated with a fairly quick recovery. Some prolonged nasal tip swelling can be expected.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How should I take care of my incisions and sutures after surgery? I had eyelid surgery yesterday and my doctor did not give my any directions as to how to take care of them. My friend told me I should clean them every day with hydrogen peroxide and then apply ointment. Is this correct?

A: After surgery wound care is frequently misunderstood. Hydrogen peroxide has been historically used and is still recommended as a wound agent for sutures lines. However, it is important to recognize when and how to use it to avoid adverse healing and scarring effects. Hydrogen peroxide can help remove small clots on suture lines which develop right after surgery due to its effervescent bubbling action. (the effect of catalase) Using a Q-tip several times a day right after surgery to get the blood clots off suture lines is beneficial as these blood clots are a potential breeding ground for bacteria.  However once there are no more clots on the suture lines (as they should all be gone in a day or two after surgery) hydrogen peroxide should not be used. It has been shown hydrogen peroxide applied to wounds can actually impede their healing and lead to increased scarring as it destroys newly formed skin cells.  Once the clots are gone only topical ointments should be used to aid in the healing and protection of new skin cells so that complete re-epitheliazation across the wound can occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have liposuction on my calfs, but,I have been told by several doctors not to do it? Is it safe? I see on your website you do calf and ankle liposuction.

A: Liposuction can be done safely on the lower extremities, including calf and ankle liposuction. It is not a question of safety but effectiveness. Can enough fat be taken from the right places to make a visible difference. While most people that seek liposuction below the knees would like a large circumferential reduction, such changes are not usually possible. However, selective small cannula liposuction done in the right areas (high inner calf, lower inner calf, low posterior calf and inner and outer ankles) can give the calfs and ankles some shape so that they don’t look like ‘cankles’ and straight tubed calfs.

The issue with liposuction below the knees is that there will be some prolonged swelling due to the high venous pressures that naturally are present in the ankle and feet. It usually takes about 3 months for the full effects of the procedure to be seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a custom skull implant made for the back of head to correct its flatness. But I have some basic questions if you don’t mind about the process and how it all works as well as some question about the surgery itself.

1) How many times do we physically have to meet? How many trips will I have to take to your office?

2) My biggest concern is that the implant has be made exactly to the specifications and contours of my sKull so that there are no “pockets” between my skull or the implant (no matter how small or microscopic, i don’t want to risk complications) I want it to fit “like a glove.” Will the implant be custom made at the time me meet? After? Will I have time to see and try the implant, (meaning see how it fits on the back of my head by actually applying it on my head externally?)  How will I know what the final result will look like? How accurate are the computer models?

3) How are the implants designed? Can you tell me more about the process and steps? I.e: we meet, you take measurements of my head, look at CT scans, and send info out to the lab where its made? What is the actual process from the moment I agree to surgery 

4) What complications (if any) have you had in the past with surgery of this nature? How many patients needed revision or had complications? 

5) What are the risks or side effects post op? What should I expect? How long is recovery and healing time? How long does it take for the scar to heal, or for any swelling to go down? Is there a high risk of infection?

A: In answer to your questions about a custom skull implant:

1) The only times we really have to meet is the day before surgery when you come for your surgery. Any followups are done by phone or Skype.

2) The implant will be made off of your 3D CT scan (which you can get in your local community). It is made by a computer design process to the dimensions that I provide. This way it will fit perfectly, like a cap on a prepared tooth. This is all done before surgery and does not require you to be seen. During the design process I will provide with the PDF files so you can see exactly what the implant looks like and its size. This process takes about 3 weeks to make once they (Medical Modeling, Golden Colorado) get the CT scan.

3) As above. It all starts with you getting a 3D CT Skull scan.

4) I have done many custom implants and skull augmentation with implants and bone cements. The only problems that I have seen are aesthetic…was it big enough? was it smooth and symmetric? My experience shows about a 10% risk of a revisional surgery for some aesthetic adjustment. In the case of a computer-generated skull implant, the computer design process helps avoid most of these aesthetic issues. I have yet to see an infection or any significant wound healing problem.

5) Other than some swelling, most patients do not have much pain. There are no restrictions after surgery and one can return to any activity as soon as they feel like they can. The incision heals very quickly and, even with swelling, most people don’t even notice it since the head shape just becomes more normal. In rare cases, some swelling may go forward to the eyes but that depends on how much scalp dissection is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in thigh lifts. My inner thighs run together and there are several rolls of skin that meet and rub when I walk. Sometimes this causes irritation of the skin. I would like them reduced and lifted so there is a gap between them. I also have a pubic area that hangs a bit low so combining thigh lifts with some type of tummy tuck would be ideal. Can these two procedures be done at the same time?

A: Inner thigh lifts can be very effective at improving the shape of the inner thighs near the pubic region. In most women, however, getting an actual thigh gap from the procedure is expecting too much. There is a limit as to how much skin can be removed in a thigh lift and how much fat can be suctioned from the area at the same time. The more skin that is removed, the higher the risk of scar widening and scar migration below the groin crease, making the scar more visible. While improvement is always seen in inner thigh lifts, it is a balance between the improvement in shape and the length and location of the scar.

Thigh lifts and tummy tick surgery can be combined without any vascular compromise issues between the intervening skin. (although this would depend on how long and close together the two incision lines will be) It does make one’s recovery more difficult with tightness of both the abdominal wall and bending at the thighs, but it can be successfully done as a combined procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering facial implants to rejuvenate my young but old-looking face. I am 37 years old and underwent gastric bypass surgery two years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye. I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows .I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change…not me… I want a drastic change. I lost over 1090 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery for what a plastic surgeon told me was a minimal grade 1. He said he would first try with liposuction and excision would be considered during surgery. After surgery, he told me he took 200cc fat from each side (totally 400cc) and there was no need for excision. He then advised to wear garment for six months. I wore the garment for two weeks full time 24×7, now wearing it during day time. Now its exactly 3 months after surgery and I feel not satisfied with the result. Please advise will I need revision or is it ok? I am still wearing garment. How long should I continue ? Shall I do some light weight exercise to maintain weight or will the exercise cause chest to bulge out?

A: If you are not happy with your gynecomastia reduction at three months after surgery, it is unlikely that further time is going to change that perception. At this point, there is no benefit to continuing to wear your garment. You should resume all physical activities including exercise as this will not adversely affect the result at this point. I would wait until you are six months after your surgery and then purse a gynecomastia reduction revision which will likely involve an open excision as part of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Looking into the mommy makeover. I am 35 years old and I have five kids. Exercise is not gonna get it done, I can see that now. I wanna be ready for this summer. I have attached some pictures of my body so you can determine what needs to be done.

A: Thank you for sending your pictures. They give me a clear idea as to the exact Mommy Makeover procedures you need. From an abdominal standpoint, you need a full tummy tuck with flank liposuction. You have excess abdominal skin that is loose and hanging over your waistline. Full ness from fat extends around your waistline into your back. From a breast standpoint, you need implants with a vertical breast lift. Your breasts have lost substantial volume and are saggy (ptois) with the nipples hanging below the lower breast crease.

Both breast and abdominal reshaping procedures can be done during the same surgery, hence the derivation of the Mommy Makeover name. In a single operation, often lasting 3 to 5 hours depending on what is being exactly done, a women’s body can be very positively changed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I want infraorbital rim implants but an additional concern is the changes in the skin under my eyes that I have noticed in the last three to four years.  I have attached a PDF of some of my eye pictures.  They shows the bunching up and “crepey” skin that tends to exacerbate my undereye issues and tired appearance.  Even though the lower photos are the effect with an extreme smile, this tends to occur even with a mild smile, and really affects my self-esteem.  I was wondering how infraorbital implants and/or fat relocation will ameliorate these folds.  Though I had a series of three micro laser peels this last year, they did little to address this issue.  I just would like to be realistic as possible in terms of the outcome of this procedure.

A: The smile animation ‘deformity’ around the lower eyelids (under eye wrinkles) is a tough one since it is a muscular action effect and not a structural problem. No amount of static skin resurfacing will help a dynamic movement issue. The  infraorbital rim implants will make some improvement in it due to volume expansion and some diminution of muscular excursion but ultimately animation wrinkle deformities respond best to Botox injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It appears that very few plastic surgeons offer a permanent solution for labiomental fold treatment (reduction). After reading your case study on the subject, and considering other options, I’ve decided to either address this issue with Silikon-1000 a permanent filler, or with an implant which I prefer. You would be my choice of surgeons for the implant. But I have one problem. As far as I’m concerned, I do not want any scars, regardless of how small or imperceptible they may be. My question to you is… Would it be possible to have the implant put in place from inside the mouth rather than through small incisions on the skin?

A: Labiomental fold treatment (reduction) is a challenging procedure and I would not refer to any treatment of it as permanent since facial aging is a progressive procedure. I would not recommend a subcutaneous labiomental fold implant be placed through an intraoral incision. Besides not being able to get it in the ideal place, there is going to be a higher risk of infection dragging the implant through oral mucosa. I think an implant is the right procedure for labiomental fold reduction, just not placing in through the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face is really chunky and rounded and just full. I would really like to have a slim face with  defined cheekbones and a square jaw. I was curious about whether any types of would be capable of altering my facial features. Also if I have facial surgery can I get liposuction in various areas consisting of belly, butt, back, and male breasts, thighs, and arms.

A: In regards to your face slimming desires, the first most important is whether any significant slimming effect with better definition can be obtained. Not all face types can be converted into those desired changes. I would need to see some pictures of your face to determine what may be possible. Fat removal procedures can have some mild to moderate facial slimming effects. Skeletal augmentation such as cheeks, chin and the jawline often produce more profound facial changes.

When it comes to liposuction in men, by far the most common areas would be the abdomen, flanks (love handles) and chest. Thigh, arms and back would be very uncommon requests. (quite frankly I have never had a male request for liposuction in those areas my entire practice career) This raises the question of what your overall weight and body type is. I would be curious to see pictures of these areas of body concerns to determine if liposuction is the appropriate treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting hip implants to achieve an hourglass figure. I hate the indent I have in my hips and would like implants to be inserted up over the iliac crests if I’m not mistaken. The indent has gotten bigger and worse as I tried to gain weight in the hips, but of course I can only do so much with the bone structure I have. My questions are, how wide can the hip implants be? I’m typically trying to achieve at least around an inch. And also I’m interested in getting a labiaplasty to reduce my labia, so could this procedure be done at the same time? Thanks

A: Hip implants are an option for your hip indents but placing them that high up over the iliac crests may be problematic in terms of the waistline effects of wearing clothes. Given  your body type I would first consider a fat transfer as you have good volume to be harvested from the knees, inner thighs and some from the abdomen. This is the way to put fat there as opposed to trying to gain weight by your diet. While fat is unpredictable in terms of its survival, it is perfectly safe, natural and would prepare the tissues better if you ever considered placing implants in that area. (although the goal would be to never have to exercise that option) Labiaplasty could be performed with either fat grafting or implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It appears that very few plastic surgeons offer a permanent solution for labiomental fold reduction. After reading your case study on the subject, and considering other options, I’ve decided to either address this issue with Silikon-1000 a permanent filler, or with an implant which I prefer. You would be my choice of surgeons for the implant. But I have one problem. As far as I’m concerned, I do not want any scars, regardless of how small or imperceptible they may be. My question to you is… Would it be possible to have the implant put in place from inside the mouth rather than through small incisions on the skin?

A: Labiomental fold reduction is a challenging procedure and I would not refer to any treatment of it as permanent since facial aging is a progressive process. I would not recommend subcutaneous nasolabial fold implants be placed through intraoral incisions. Besides not being able to get it in the ideal place, there is going to be a higher risk of infection dragging the implant through oral and nasal mucosa.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know which its a better choice between a facelift or laserlift. My concern is since my face is thin and non-fat, its more sagging skin around my jaw line and a little on my neck. I don’t know if the laser will really tighten my skin or cutting it will produce a better result.

A: While I don’t know what your face looks like and the degree of  jowl and neck sagging that is present, it is fair to say that any form of a so called ‘laserlift’ pales in comparison to what a real surgical facelift can do. All so-called non-surgical ‘facelift’ technique only produce a mild amount of skin tightening that is very temporary at best. Regardless of the device used, its results are extremely modest and are best reserved for those patients whose skin laxity issues are so slight that the consideration of any form of a facelift is premature. Think of non-surgical facelift methods as a delaying tactic to push back by a few years the need for surgical improvement. In short, non-surgical facelifts are not a substitute for even the most minor form of a surgical procedure. Be aware that facelifts today have evolved so that they are done in minor to major forms depending upon the amount of jowl and neck work needed. They range from simple jowl lift procedures to more extended neck-jowl lifts. Often the debate between non-surgical vs surgical facelifts comes down to a decision between non-surgical skin tightening and a jowl lift. (level 1 facelift) For the economic investment and duration of effect, the far better value is almost always the surgical facelift hands down.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year-old male that has Poland’s syndrome and am interested in pectoral implants. Can you fix my chest?

A: I can see from your pictures that you have a mild case of Poland’s that has affected the right side of your chest. The right pectoralis muscle is a little bit smaller and the nipple-afeolar complex on the right side is a little higher. I suspect that when you raise your right arm, compared to the left side, that the asymmetry between your chest sides becomes even more apparent. There are two approaches you can use for your improving the appearance of your Poland’s chest deformity. One approach is to just place a small pectoral implant on the right side with a nipple lowering procedure. Fat injection grafting as opposed to an implant can also be used although it is less reliable than an implant in terms of permanent volume. A second approach is to enhance both sides of the chest with pectoral implants (right bigger than left) with a right nipple lowering procedure. The choice between the two depends on how you view the normal left side of our chest. If you are happy with it, then you go with the first approach. If you are looking for improvement on both sides, then you go with the second approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was told in a consultation with a local plastic surgeon that I needed cheek implants, chin reduction (just shaving the bone down and removing some fat/skin), and a little off the hump in my nose. That is the basis for my inquiry. Even though those were his suggestions, I still wanted to keep looking because I didn’t see that he had a very extensive client base where he had performed all of those at once…or more than one procedure at the same time. 

I normally pose differently and make myself look better in pictures, but my profile is very flat in the cheek area and prominent in the chin. I’d like to get this corrected somehow, but I think with so many things to address at once, I get concerned that the surgery would be very noticeable and I would look like a different person all together… 

A: In reviewing your pictures, I could make the following comments:

Your vertically long but non-projecting chin would be best treated by an extra oral vertical reduction ostectomy. (submental chin reduction) A burring technique would not remove nearly enough. You need at least 8mms or more off to really make a difference.

Your flat mid facial profile is ideally treated by a combination of paranasal and malar shell cheek implants. This will help pull out the entire midface. (both the nasal base and the cheeks)

You do have some significant facial asymmetry that actually affects the whole left side of the face. (which is shorter) The chin reduction will help with the lower facial asymmetry. The eye asymmetry, however, will not be improved.

One realization is that these changes will make a facial difference with much better balance…but it will likely be noticeable as your face gets vertically shorter and more horizontally projected.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I consulted with a local doctor and he said that because of the height and projection of the nasal implant it made my nostril more visible. I think I’m leaning more towards rib cartilage as use for the implant. What I want to accomplish is a nose that’s less deviated, less nostril visibility and appears less short. Also, being that I have thin skin, what can we do to prevent the rib graft from being visible when someone is looking at me? At the moment, my nose looks thin and skeletal like and I want to remedy that. 

For my chin, I want the implant removed and fat grafting done to the area. I just want a chin with an appropriate projection in relation to my face and nose. Also, I would like to see if we can use fat grafting to restore a natural jawline to my face before resorting to implants. I would like fat grafting to my nasal labial folds as well as the cheek/hollows of my eyes. 

A: There us nothing wrong with using injectable fat and that is clearly a treatment approach that you find most comfortable. However, you need to be aware that fat grafting never works the same as an implant regardless of how it is presented in surgeon’s websites. Fat grafts are soft and don’t have the same push on the overlying soft tissues. As a result, the amount of augmentation and the definition it creates is far inferior to a firm implant. But with that being said, I think fat grafting is reasonable since you have other fat grafting needs so ti is worth the effort. There is certainly nothing to lose by so doing.

It is difficult in any rib graft to a nose with thin skin to not have it look skeletal. Ways to lessen that aesthetic risk are carving the edges of the graft so that they are round and not sharp and to cover the rib graft with a thin layer of allogeneic dermis. Together these two approaches can be effective at softening the look of a rib graft to the nose.

In replacing a chin implant with fat, it is again important to know that it will not create the same effect and many not even survive inside the relatively avascular lining surface of the chin implant pocket. But again it is a reasonable approach with little risk other than complete graft absorption.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had buccal fat pad removal (buccal lipectomy) recently and am already seeing positive results. I can see my strong cheekbones a lot more. However, there are parts of my face that still display bits of fullness. Based on your responses to other questions, it appears I still have some perioral mounds. I am considering liposuction in this area. However, my concerns are a return of fat after treatment. I’ve read different online opinions that indicate fat can return after liposuction. As such, my questions are:

1. If I get liposuction on my perioral mounds will the fat go back to my buccal fat pads to compensate for the fat loss in my perioral mounds?

2. If I choose not to get liposuction on my perioral mounds, but either gain some weight, or stay the same weight, will my buccal fat pads eventually return? From what I recall, I had my surgeon take out as much buccal fat as possible, but the temporal part was of course left alone. Can buccal fat regenerate?

3. Lastly, I am also considering some type of laser resurfacing procedure for acne scarring but I am worried the regeneration of new skin cells promoted by these laser procedures will bring my buccal fat pads back. Is this possible? 

A: When it comes to liposuction, you have to separate face and body liposuction as the long-term results can be quite different. This is especially true for the unusual buccal lipectomy procedure. To answer your specific questions:

1. Once the buccal fat pads are removed, they will never come back.  A buccal lipectomy is the most unusual of all fat removal procedures in the body as it is a total glandular excision not subtotal fat extraction. Fat only returns in the body by cell hypertrophy not new fat cell growth.
2. Buccal fat cells, like almost all fat cells in the body, do not regenerate or make new cells. Only the residual or existing cells can get bigger.
3. A skin laser treatment will have no effect on the deeper underlying fat in terms of ever promoting fat cell hypertrophy or fat cell replication.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift proceure but I must admit that the procedure worries me. There seems to be lots of unhappy results, in which columella has gotten longer, nostrils became wider, and people end up looking like rabbits etc . My local surgeon says that in his experience, after the lip lift,  is that with time the lip always goes back to its original position, due to the weight. Do you use a special kind of suture and/or technique that would prevent the lip from pushing back down?

A: While the subnasal lip lift procedure is relatively simple to do from a surgical standpoint, it is a procedure that has no tolerance for error. From selecting the right patient, to the design of the skin removal area and to the method of closure, all impact what the final result will look like. There are several key points to a successful lip lift result. The first is to recognize that its effects are on the central or cupid’s bow area of the lip and does not extend to the mouth corners. Secondly, the excisional pattern of design should mimic exactly the curvatures of the lip-nasal base junction and should not extend around to the side of the nostrils. Third, the amount of vertical skin excision (as measured at the philtral columns) should never, and I repeat never, exceed 25% in a man and 33% in female. Lastly, no attempt should be made to prevent some after surgery relapse by sewing muscle, removing muscle or otherwise trying to secure the skin down in a tightened fashion.

If you add up all of these points together, one can see that the key to a happy subnasal lip lift result is to not try and over do it. Overcorrection and lack of attention to detail makes for most of unhappy subnasal lip lift results.

It is important to recognize that in the first six months after surgery there will be some ‘relapse’ of the initial result. This is due to natural skin stretching from lifting any type of tissue upward. (no different than a browlift or facelift) My observations have been that it is about 25% to 33% vertical change in the first six months after the procedure. But trying to overcorrect to factor in this after surgery lengthening is a mistake. It is far better to have a natural looking lip result that a patient wants to secondarily revise (about 10% do) than to have an initial overdone too pulled up look that the patient is waiting months for it to settle down and drop.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some type of temporal plastic surgery. As you could see from my pictures my temples are not symmetrical. Even though I was born with my temporal muscles having a natural arch, an injury on the left side tore that muscle At least that’s what I hypothesis. What are your thoughts, regarding an operation that will make my skull shape even again? Thanks for your time.

A: What I am seeing is that you left temporal region is larger than your left which is most likely due to a difference in the size of the muscles in that area. This can be approached by two different types of surgeries depending upon which side of your head you like the best. If you prefer the bigger left side, then a temporal implant  can be placed from behind the ear under the muscle to make it bigger. If you prefer the right side, then a temporalis muscle reduction would be needed to make that muscle smaller through a vertical incision in the temporal hairline. Or if you don’t like the bulging on either side, then the temporalis muscle could be reduced on both sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty, sliding genioplasty and a lip lift.  I was born with a unilateral cleft lip and I want my face to be more symmetric. What procedures do you think should be done?I have had one rhinoplasty and I have an L shaped implant. I would like for my nose to be more narrow and symmetrical. With the lip lift I want my lip to be about 15mm or shorter. I have a chin implant, but I think with the genioplasty it will make my chin balance out with the rest of my face. 

A: I have done some computer imaging done on your chin, jaw angles, lip and nose. I think it is fairly clear that your chin is fairly short even with the implant in place. This shows that the jaw is rotated up and back (short) and is why the jaw angles are high. A sliding genioplasty (possibly leaving the chin implant in place and moving it with the bone) may be needed to get the 12 to 15mms forward movement you need. Moderate jaw angle implants in the back will help fill give them some more definition. You don’t need your upper lip lifted by 15mms, that would be too much. Something like 5 to 7mms would be more appropriate. The question here is whether it should be done by a subnasal lip lift (lift only the central portion) or a vermilion advancement which moves the whole lip up. (probably better) The nose is challenging because of your very thick skin and the naturally thicker tip skin that many cleft patients have. To make a real difference, the implant ideally needs to be replaced by an L-shaped rib graft so you can get more of a push/lift on the skin and a sharper tip point. The implant just makes it rounder and still short.

The imaging done is to just figure out of these procedures are beneficial. The fine details of it and the degree of changes is an issue up for discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting deltoid implants. I am a 36 years old male and I have very short clavicles and a larger than average head to make my shoulders appear even more narrow. I have read a response to a deltoid implant question it made me come up with a few questions.

1. The response stated that the implants can be place in a intramuscular location. Does that apply to an implant for both lateral and posterior deltoid heads? If not, what type of deltoid implant can be placed in the muscle?

2. How much actual width could be added using the largest implant possible without effecting practical functions (such as lifting the arms sideways)? I attached a picture of my narrow shoulder along with a photo-reference of a look I’m going for. I’ve provided of a picture of the look I’m trying to achieve with surgery. The red area is what would be the ideal mass added with an implant. Would this be possible?

A: When it comes to deltoid implants, an understanding of the anatomy is important when considering implant placement. The deltoid muscle is a broad muscle that creates the rounded contour of the shoulder. While it technically has three sections or muscle bellies (anterior, central and posterior), it is best to surgically think if it as single muscle belly as they are difficult to separate. The muscle is also enveloped by a fascial lining that is most manifest on its outer surface. Thus implants can be placed either submuscular (under the muscle) or subfascial. (above the muscle but under the fascia)

When considering where to place a deltoid implant, one has to take into consideration the movement of the muscle and the arm. As the arm lifts away from the body, the deltoid muscle contracts and becomes shorter. There is the risk, therefore, that a submuscular implant placed directly under the central belly of the muscle could interfere with arm motion. This would be less true for a very small implant or one that is placed closer to the front or back edge of muscle, but this then would not have much of a visible effect as you desire. This makes the subfascial location preferred in most cases.

Lastly there is the issue of incision location to place a deltoid implant. This is almost always best done on the back side of the arm where it meeds the trunk, keeping any scarring in the least visible location.

Your photo reference indicates a result that probably can not be achieved. Maybe half to three-quarters of that amount of shoulder augmentation is more realistic. Think of adding about 1 to 1.5cms width per side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in depressor septi muscle surgery. When I smile the tip of my nose really gets pulled down. Also my upper lip crunches up and a wrinkle appears across the top of my upper lip. I have read online that this is due to a muscle under the nose and if it is released my nose and lip will look better when I smile. How is this surgery done?

A: The muscle you are referring to is the depressor septi muscle. It is attached from the upper jaw at the base of the nose upwards where it attaches to the nasal septum and the back part of the nasalis muscle. It is this muscle then when overactive pulls the tip of the nose down an pulls up on the upper lip which sort of crunches the nose and lip together. In rhinoplasty this is known as the smiling deformity.

This smiling deformity is often treated at the time of a rhinoplasty or can be done as an isolated procedure. The surgical techniques for treating an overactive depressor septi nasi muscle vary and consist of either an(intranasal resection or an intraoral release/transposition. A recent study has shown that the both techniques produce similar effects in how much they decreased the effects of smiling on the length of the nose, tip projection or upper lip length.

The intranasal approach is historically more common due to the anatomic location of the muscle when doing a closed rhinoplasty. It has a side benefit of decreasing the interalar distance. The intraoral approach has been more recently described undoubtably due to the now widespread use of open rhinoplasty. Coming from below (inside the mouth) allows  an actual release and transposition of the paired muscles. This results in an increased fullness to the upper lip afterwards.

Either depressor septi muscle surgery techique can be done under local or IV sedation and has a minimal recovery with some short-term upper lip swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently struggling with a flat back of the head and a small head too. Can skull reshaping surgery be done on me to add any implant to mainly the back and top parts of my skull that would give me a decent sized head that is also well rounded ? How effective is this surgical procedure and what are the possible negative effects of any implant on my actual skull?

A: Skull reshaping (augmenting a flat area) can be done to almost any part of the skull and its limits are based on how much the scalp can stretch to accommodate the volume of augmentation. Based on what one’s expectations are, it can be a highly effective procedure. I would have to see some pictures of your head that show the flatness and then do some computer imaging to see if what skull augmentation can do is sufficient. It is always important before surgery to find out if the changes meet a patient’s expectations and to determine how much volume is needed to create that augmented effect.

There are no known long-term effects of the materials used in skull augmentation as it relates to the bone or the overlying scalp tissues. Bone resorption is not known to occur nor is scalp thinning over it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding chin reduction. Could my chin be reduced in height vertically with out having my chin split into pieces? I think that is too much of a risk and to much time to recover from for me. Is there something else you can possibly do like burr it upwards from underneath as well as backwards because I have what I consider to be a pointed chin. I would like to have it rasp to the point it looks wider, flatter and shorter. Is this surgery at all available? How much is allowed to be vertically shaved off before it reaches into the too much taking off zone? I would prefer the incision inside my mouth being as though I’m a person of color but I’m willing to take that risk to have the chin exposed through the under cut to obtain the result I so desperately desire. I’ll just get my scar revised if that’s what it takes.

A: The type of chin reduction you are referring to is common and is known as a submental chin reduction. While burring is used for some minor shaping, more significant reduction is done by a saw blade cut and the edges then burred. This can make a radical reduction in vertical chin length and definitely can take a pointy chin and make it shorter, wider and flatter. With this much vertical chin reduction, the submental approach is best anyway because it allows the excess soft tissue to be removed and tightened as well to prevent a witch’s chin deformity. The amount of bone reduction that can be done is based on the location of the tooth roots and the exit of the mental nerve which is usually above the 10 to 12mm mark from the lower edge of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Brazilian Butt Lift. Could this procedure include having liposuction for weight loss reasons as well as butt enlargement? It seems like you get two benefits at once, a bigger butt and dropping your weight at the same time.

A: Every Brazilian Butt Lift requires liposuction to harvest the fat that needs to be transferred by injection into the buttocks. This almost always comes from the abdomen, flanks and waistline and as much fat is taken as possible in most cases. But to call this liposuction harvest, or any liposuction procedure, a weight loss method would not be appropriate. That is not what it accomplishes. Liposuction is a shaping technique but it does not create any substantial or sustained weight loss in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i want my forehead made smaller with a shorter hairline. I would like to have a procedure at your facility to have the central frontal bone vault reduced to about 5mm and the glabella the triangular area in between the eyes over the nose and under the brows,I had a interview with a previous surgeon who was actually to far from me to travel but he was saying my scalp is flexible   Enough to bring it down to 2 cmd maybe another half once he loosened this area underneath my scalp. I forgot the name of it,do you have any idea what he’s referring to and do you use this same technique?

A: You are referring to a hairline advancement procedure as part of an overall forehead reduction. This requires the scalp be loosed up so it can be brought forward and the hairline lowered. The more natural scalp flexibility one has, the easier and more hairline advancement that can be achieved. This is often done with frontal bone remodeling such as frontal bone reduction and some brow reshaping/contouring. You are correct in assuming that about 5mms of frontal bone can be safely reduced by burring.

Dr. Barry Eppley

Indianapolis, Indiana