Your Questions
Your Questions
Q: Dr. Eppley, I am a young man and I am embarrassed of the shape of my head. My head circumference is about 58 cm which seems to be only about 1-2 cm more than the average but the shape is abnormal- as it gets wider above the ears and temples on both sides. What is very surprising when I clench my jaw both sides of the head gets wider (about 0.5 cm) each side, and when I widely open my mouth both sides of the head get thinner and head looks almost normal. Would you be so kind to answer my questions. Is there any possibility to reshape my head on both sides. If yes what is the potential risk of such surgery- is there any chance to damage my brain, nerves, veins etc and is such surgery a big risk for my health and life? Does the surgery may affect in a bad way circulation of the blood in my head which my cause for example hair loss (it is extremely important for me to protect my hair because that is the only way I can mask shape of the head). What is the recovery time? I train bodybuilding and boxing especially the second one is obviously extremely contact sport- will I be able to continue my two passions and how long after surgery will I be able to come back to training?
A: What you are describing perfectly are thick temporalis muscles which is making a major contribution to the width that you are seeing above your ears and into the temple region. This is evidenced by the widening effect that occurs when you clench your teeth together (temporalis bulging) and why it gets thinner when you open your mouth. (stretches and thins the temporalis muscle) This dynamic head width changes indicate that a temporal reduction (temporalis muscle shortening/relocation procedure) would be very effective. This results in a 5 to 7mm change per side (1.0 to 1.5 cms transversely combined) when these muscles are shortened. In addition a small amount of bone burring can be done at the same time. Not that you know the correct procedure, the answer to your questions are as follows:
1) There is no risk to your brain or any major blood vessels or nerves.
2) There is no risk to your general health. This is an aesthetic operation.
3) This surgery does not affect the circulation to your scalp or head.
4) There is no risk of any hair loss.
5) The recovery is fairly quick, just some swelling on the sides of the head that looks pretty normal in a wee. There are no restrictions after surgery.
6) You could return to contact sports within two weeks after surgery.
7) I will have my assistant Camille pass along the cost of the surgery to you later today.
The biggest issue in performing temporalis reduction surgery is that fine line incisions are needed on the side of your head to perform it. These incisions do not cause any hair loss and I do not shave the incision line to perform them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation surgery but needs some basic recovery questions answered. What is the average time you recommend returning to work? I already have dates that I’m taking off for this year for vacation and other things, so I don’t want to have to take too much time off work. Also, I have an 18 month old, and she is a big girl for her age right now! She is a momma’s girl and is always wanting me to hold her and carry her, so my other concern was being able to lift her and carry her. What are your lifting requirements after surgery?
A: Returning to work after breast augmentation is highly variable based on what one does, how physical their job is and their own discomfort tolerance. On average, it can be anywhere from 3 to 5 days. I place patients on arm range of motion exercises the night of surgery and the more you move the quicker you will recover. I have no lifting restrictions after surgery and you can lift anything you want without fear of hurting the result. Your body will tell you what you can and cannot do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in deltoid implants. I am a 25 year-old male who has done bodybuilding for the past two years with great results. This is with the exception of my deltoid muscles, which are one of the most important and prominent muscles on a male body. My dad has also weak shoulder muscles so I think it’s genetics.
Now my questions:
1. How are the (silicone ?) implants placed and where exactly, so that the most obvious effect in width is achieved ? Are they placed into the muscles or above, because one should not feel the material when one touch the shoulders if possible.
2. How thick are they? How much shoulder width can be added with the implants ?
3. What are the risks during and after such a surgery?
4. Is the result permanent?
A: In answer to your questions about deltoid implants:
1) They are silicone implants and are placed either subfascial or intramuscular, depending on which head of the deltoid is being augmented. Of the three heads of the deltoid, the most commonly augmented are the lateral and posterior heads with the implant placed between them. This also creates the greatest amount of width augmentation. It would be helpful to see exactly by pictures which areas of the deltoid you want augmented.
2) Since there are no real deltoid implants commercially made, I use calf implants which have three sizes (volumes 70 to 170ccs) with up to 2 cm of thickness per implant.
3) The risks of surgery are a permanent scar, infection, undercorrection/overcorrection, and implant malposition. (which are the standard risks of any implant-related surgery)
4) The implants will never degrade or breakdown and thus add permanent muscle augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. As you can see from my attached pictures, I have a bulbous tip and a deviated septum. I hope to reduce the bulbous tip as well as straighten my nose. Can you please notify me if this can be done? Also from the pictures can you tell me whether or not I have thick nose skin? If I do have thick skin, will I still be able to reduce my bulbous tip and gain a more straighter profile on my nose?
A: I think you are an excellent candidate for rhinoplasty. You have a wide bulbous tip with played domes of the lower alar cartilages with intervening fat. But it should shape up nicely with an open rhinoplasty where the cartilages can be reshaped and brought together to create a much more narrow tip with more refined definition. I do not see that the thickness of your skin as being a limiting problem for getting a good rhinoplasty result. You have intermediate skin thickness which will shrink nicely when the underlying cartilages are reshaped.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry correction. My face is crooked, particularly my chin and jaw. When I smile my chin pulls to the left and makes the jaw asymmetry look worse as it points to the left. The rest if my face on the left side is also uneven. My left eye and eyebrow are lower and my cheekbone seems smaller. When I look in the mirror I don’t look too bad but it looks much worse obvious in pictures. Can my facial asymmetry be fixed?
A: Like many cases of facial asymmetry, it rarely is just one area of the face. What you are describing is a more complete unilateral or one-sided facial underdevelopment. This is evidenced by a lower eyebrow and eyeball position, a flatter cheek and a shorter jawline distance from chin back to the jaw angles. In essence the vertical length of the face is shorter on your left side than your right. The jaw asymmetry in particular is magnified when you smile as the soft tissue of the chin is pulled back and deviates to the less developed side.
There are a variety of facial asymmetry procedures that can be done from the eyebrow down to the jawline. What you would do depends on how much of the facial asymmetry you want to treat. The chin/jawline often displays the most severe aspects of facial asymmetry and is often the most important area for many patients to correct. This can be treated by a sliding genioplasty to realign the bony chin to the midline. This can be possibly combined with a small jaw angle implant in the back to completely lengthen the entire jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How much will a rhinoplasty surgery cost me? I have Aetna Insurance and I want to know how much they might cover. By the way I have breathing issues and I went to a doctor and he told me my septum needs correction and my insurance might cover half of the whole surgery price.
A: Let me provide you with some clarification on your nose surgery and a better understanding about the costs of such surgery. The concept the ‘insurance may pay half of the whole cost of the procedure’ is both misinformed and overly simplistic.
What you are seeking is a nose procedure known as a septorhinoplasty. This is a procedure that combines the correction of a functional problem (septum and turbinates) and an aesthetic nasal issue. (rhinoplasty) While they are commonly done together and one does affect the other one, they are viewed economically as two separate issues no matter where you are having the procedure performed. The septum and turbinates are functional airway issues and are often covered by insurance. The rhinoplasty is an aesthetic issue and is never covered by insurance for common aesthetic reasons. Just because the two procedures are done together does not in any way mean that insurance is covering any cost of the rhinoplasty. Those fees must be paid out of pocket and in advance and includes the surgeon’s fee and the operating room and anesthesiologist’s time to do it. When done together a surgeon may choose to lower their professional fee for the rhinoplasty as a courtesy although they are under no obligation to do so.
Thus the only thing that insurance covers has nothing to do with the rhinoplasty. And if you do not do careful financial analysis beforehand (how much is your deductible, what is your percentage of costs beyond a certain dollar amount of what insurance pays), you could easily end up paying more for the whole procedure using insurance than if you paid the entire septorhinoplasty as a complete cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I am wondering what all can be done to make my forehead go more up and down rather than how it slants severely back starting immediately above my eyes. After looking up pictures and seeing people with different types of foreheads I think I have found the answer to my problem, or rather, what I would desire to have for myself. I just don’t know how much can actually be done in the present time and how realistic my ideal results are. I would like to add quite a bit to my forehead to make it more vertical instead of so severely slanted and I was wondering if I am desiring something beyond the limits that are currently set? I gave a picture of myself from the side with wet hair to give an accurate shape of my skull as a whole, especially the slanting forehead/top of head, and then another picture of what I am thinking I would like my forehead to look like. I look at pictures of myself (such as this one) and worry if it is only a small amount that can actually be added onto one’s skull, and if I am drastically unrealistic in my hopes, what are the limiting factors? Some of the ones I read about (like the amount the skin will stretch on one’s head) seem like the major one.
A: What you are seeking is a commonly performed aesthetic craniofacial procedure, forehead augmentation. This is done for a variety of forehead shape concerns, one of which is to change a sloping backward slanting forehead to a more vertical one. While the limiting factor is how much the scalp and forehead skin can stretch, the result you are desiring to achieve is largely very realistic and within the ability of the scalp to accommodate a greater volume and convexity underneath it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had eyebrow hair transplants 12 days ago. Anyway, it seems like the transplanted hairs have been falling out these past few days. There wasn’t much crusting or scabbing, and I have not noticed any blood on my eyebrows. I’ve spoken with my surgeon who has told me that it’s normal for the transplanted hairs to fall out. But I’m still a little concerned, which is why I would like your opinion as to whether this shedding is normal? If so, why do these transplanted hairs fall out and not continue growing?
A: The basic concept of any hair transplantation procedure, including eyebrow hair transplants, is to do follicular (hair bulb) transfer and implantation. The hair shaft is merely a handle by which to do that. It provides a convenient means to move the hair follicle into a new site. The shock of the transplantation procedure causes the shedding of the dead hair shaft 10 to 14 days after the procedure and is both expected and normal. The transferred hair bulbs are intact under the skin and new hair will not be seen until grows out from the follicle. Given the rate of hair growth, it will take months to see new hair emerge and a full six months to have the desires hair length that you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a middle-aged man who have been considering elective surgery for a long time. Due to my temple hollowness, I have had injectables (Radiesse, Sculptra, fat) in the area for long time, but with very limited effect and minimum duration. I am looking now into a more permanent solution, like temporal implants. On the other hand, due to my “sad look” a lateral brow lift has been offered to me several times, however, do you think that correcting the temples could fill up the area around the orbital contour or a lateral brow lift could still be needed? If so can both procedures be done together? My separate question to you is to whether a facelift could be performed at the same time as the one or the two procedures discussed above. Thank you in advance for your reply.
A: Temporal implants would be the only effective treatment option with your type of temporal hollowing. Your thin facial tissues have little fat and this explains why any type of injectable filler, including fat, can persist. Subfascial temporal implants will provide a permanent result by muscle augmentation. Temporal implants will not lift up the tail of your brows, n matter the size. That will require a temporal browlift, best done in men through a transpalpebral approach using an endotine fixation device. A facelift can certainly be done at the same time with careful placement of the incisions around the ears.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of cheek implant I think. I am not sure whether I have weak cheekbones or whether they are average or it is really a lack of fat or a lack of orbital rim development that gives me those lines under my eyes near the cheekbone. (Not tear trough) I have gotten comments on having a sunken/droopy “eyes” look when I’m cutting body fat and I’d prefer to have a much more healthy looking eye area when I’m at a lean fat %, just not too feminine either. I just wasn’t sure if that was primarily due to the cheekbone, orbital rims, or an odd lack of fat storage in that area of the face. So if am just to augment my orbital rims (lateral, inferior) and perhaps a bit of the anterior cheek (not too feminine) don’t you think fat transfer is my best option rather than a cheek implant, since a cheek implant doesn’t really touch those areas?
A: Cheek implants are your best treatment option but not the way you currently think of them. You do have a ‘weak’ orbitomalar area which is the result of infraorbital rim and cheekbone deficiency/underdevelopment and a thin soft tissue cover. Fat injection grafting will not work to create any sustained desired augmentation as it will be absorbed completely in less than 4 to 6 weeks after placement. The only effective approach is a combined infraorbital rim-cheek implant, probably only about 4mms thick, which will completely and permanently augment this area. While this is ideal, it will require a custom fabrication (thin tissues have no tolerance for anything less than a perfect fit that feathers on all edges) and that it will require an eyelid (subciliary) incisions to place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a follow up question in regards to your response to the question about using calf implants to correct the affects of polio. Is it not possible to use some type of balloon to stretch the skin in order to increase the amount of area available to accommodate the implant (similar to what is done for breast implants when someone significantly increases their cup size)?
A: Your question regarding the use of tissue expansion for calf implants is a good one and has some merit. However there is one major problem with it.Tissue expansion works most effectively when it has something hard to push off against. This allows the effects of tissue expansion to go in one direction, outward to the skin which can be stretched. This is why it works so effectively for breast reconstruction (ribcage) and the scalp. (skull) In the calfs, what lies underneath the fascia (which is where calf implants are placed) is the soft gastrocnemius muscle. With a very tight overlying fascia (like a trampoline) and soft muscle underneath, the effects of tissue expansion would be displaced inward and would have little effect on stretching out the overlying skin. One could place the tissue expander above the fascia in the subcutaneous plane right under the skin with the objective of eventually placing the calf implants in that plane. It is associated with a higher rate of complications (infection, visible outline of the implant) but may be reasonable given few other calf implant options. Besides tissue expansion, one could also do a first-stage fat injection to help both stretch the skin and create a better vascular bed for the second stage implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a novel browlift reversal procedure and I suspect if anyone can do it you can. A few years ago I had a brow lift performed. I hated the result. I felt like it stretched out the skin over my forehead too tight, making the bone underneath more prominent. I know in a typical scenario you might recommend a forehead reduction or some sort of burring. I however had a unique idea. I notice that in a few cases you mention the use of screws to hold the skin to the bone. I notice that when I push my scalp foreword toward my face, my forehead skin returns to the place it used to be. I was praying and hoping that you might be able to use that screw mechanism or whatever it is to hold my scalp in the forward position, returning it to its original position and thereby avoiding the forehead reduction, which I am not willing to even consider. It would mean the world to me if this could be done. I am desperate and in emotional pain. If you could make this happen it would be a God-send.
A: What you are describing is pretty much how a browlift reversla procedure is done. The very fact that you can do adequate mobilization of the forehead downward by pushing on the scalp suggests that is a real possibility to reverse your browlift. The concept of resorbable screw or suture anchor fixation to hold the released forehead tissues down is just as valid as using it to hold a browlift up. The only question then is what incisional approach to use to do it. What type of incision was used to do your browlift, endoscopic (which I assume), pretrichial, or coronal??
Using your existing endoscopic incisions (which are either two or three), the entire forehead and brows as well as the scalp behind them can be released. Then the scalp is advanced forward (epicranial shift) and is secured forward (pushing the forehead and brows down) by two or three point resorbable screw fixation to the frontal bone. I would anticipate this approach to a browlift reversal to work quite well as it is just a form of hairline/scalp advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want t know how to improve my disappearing jawline. Beginning about five years ago, the lack of definition in my jawline started to become progressively worse. Attached you will find some pictures that show a couple of different views that are fairly current as well as one from about 5 years ago to show how the lack of definition is getting progressively more noticeable as I age although I have never had that squared jaw that I like. I am in my late 40s now. While I know I will need to address the skin sagging on my lower face, jowls developing and neck laxity at some point, I am not ready for the scars associated with a face/neck lift. My hope was that by giving my back jaw more definition with angular implants, it would pull some of the loose skin simply by the sheer nature of adding some bulk but more importantly give me some definition so that it doesn’t look like my face just blends into my neck.
A: I believe you are correct on both counts. First, you are definitely not physically (or mentally) ready for any form of a jowl/necklift. That would definitely be too premature at this point in your early aging process. That day will arrive but you are at least 5 to 7 years from the benefits of that facial rejuvenation surgery. Secondly jaw angle implants, particularly vertical lengthening ones, will pick up some of the loose skin in the back end of the jaw and create more of a break between the jawline and the neck and give you more of that squared jaw look that you like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know for sure I want a Brazilian butt lift I don’t know how the procedure works. Do you take the fat from the stomach as I sure have plenty to give?
A: In a Brazilian Butt Lift (BBL), the goal is to get the maximum amount of fat possible to do the transfer injection procedure. In most people, the important question is whether they have enough fat to justify undergoing the procedure and to meet their aesthetic buttock size goals. The greatest donor site for fat is the abdomen, waistline and flanks. This is where about 80% of available subcutaneous fat depot sites exist in just about anyone. This harvest site is also the side benefit of the BBL, a natural body contouring effect from the necessary harvest site. This body site reduction is also why many BBL results look as good as they do…not because the buttock size increase is that great but but because what lies around the buttocks has gotten smaller and more shapely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have done further research on cheek implants and have a few question on them.
1) I have spoken to a few men who hated their cheek implants because they said it made them look feminine and gave the face more of a heart shape. Is it true that flat cheekbones are masculine? if so, in what circumstances can cheek implants be beneficial for a man? What’s the trick for a man? Is it too match the cheek prominence to the brow and jaw and not go over?
2) I was hoping for a subtle change in the under/lateral eye area, just to provide a bit more strength and less of that droopy look. Would fat transfer be better for this than cheek implants in my face? I very much do not want any apple look to the cheeks or even a rounded appearance.
A: The aesthetics of the cheek area when it comes to cheek implants is different for men vs. women. The proper fullness in the cheek for females is more in the anterior submalar area which creates the ‘apple cheek’ look and more of a softer heart-shaped face. In men, however, the proper cheek fullness is higher and slightly more posterior with the goal being to create a more defined and stronger cheeks. There are differences, of course, between what some men and women want but submalar augmentation in a man can definitely feminize the face. Flat cheekbones, however, would not be viewed as masculinizing feature. What you are showing in your attached picture is a very small amount of cheek augmentation but at least it is in the right place for a man. Cheek implants are always superior to injectable fillers and fat because they offer a one-time permanent solution that produces a predictable result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in belly button reshaping and it seems like you have done this surgery. Since most doctors said they can not do anything I am not sure if it is the stitching that is the problem or under the stitching. I removed my gallbladder last year, since then it has not been the same. I had a beautiful innie and now I am somewhat outie and it has been emotionally upsetting for me. I do not want to have any noticeable scars after doing the procedure or to make matter worse. I just want to make sure it will look the same as before. Please let me know how is it done and where is the scar hidden. Thank you so much for your understanding and your time.
A: Most cases of belly button reshaping is done to change outies to innies. Outie belly buttons may occur naturally or as a result of a surgical procedure as in your case. Your gall bladder was most likely removed by a laparoscopic technique of which one port was done through the belly button. Given that an innie belly button is nothing more than skin tethered down to the abdominal wall fascia, the insertion of the laparoscope disrupted this funnel-shaped attachment and now the belly button skin is just floating so to speak. Thus your innie became a partial outie now. Your belly button can be repaired by reattaching it back down to the abdominal fascia through an incision inside the belly button. This rsults in no scar on the outside. This can be done under local or light IV sedation anesthesia. I have performed this procedure numerous times for exactly the problem you now have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reduction. I really want to shorten my jawline and chin as I think the lower half of my face is too long I have a picture of me and what I hope to achieve after surgery by using a Plastic Surgery Simulator. I have no bite issues and I ideally want 1.5 cm vertical reduction of height of my jawline and chin producing a more rounder and shorter face overall. Is 1.5cm possible? Thank you
A: Vertical chin and jawline reduction can be done but not at the amount of 1.5 cms or 15mms. There is a good reason why that can not be done…the location of the apex of the roots of the lower teeth and the inferior alveolar nerve which runs through the lower jawbone. At 1.5 cms reduction, the nerve and tooth roots would be injured. There is also the issue of what would happen to the soft tissue that is currently covering your existing height of your jawbone. With that much bone removal, there would be a resultant soft tissue sag even if that much bone reduction was possible.
One issue that is common in facial bone augmentation or reduction surgery is that patients way overestimate how much change in measurements they really need. If you actually took away that much bone vertically, you would have very little jaw left. And the amount of desired in the height of our lower face in the Plastic Surgery Simulator is no where close to 15mms. That would be closer to 5 to 8mms. This is also a safer amount to lessen the risk of any soft tissue sag afterwards. One way you can measure how much bone you can safely remove is to get a panorex x-ray (a common dental film) that lays out the entire mandible like a map so the tooth roots and internal nerve can be seen. Then the vertical bone distance can be measured and actually determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. I am a 37 year old transgender. I started transition about eight years ago. I still need to have my browbone shaved and lifted a little. I’m just scared of side effects like big scars in the hairline and permanent numbness. Is the scar hidden in the hair ? Please advise. And how long before I can get back to my normal activities?
A: When it comes to brow bone reduction, there are two basic incisional approaches to it. The incision could be placed either at the frontal hairline or back further in the scalp. There are advantages and disadvantages to either incisional approach depending upon other features of the brow, forehead and frontal hairline. If one is happy with their current brow position, has a low to average forehead height (brow to hairline distance) and has any type of frontal hairline density, then the coronal (way back in the hairline) incision can be used to avoid any risk of frontal hairline scarring. But there will be a longer scar across the scalp and a greater risk of some reduced scalp sensation permanently. The frontal hairline (pretrichial) incision can be used when the brows need to lifted, there is an average to long forehead length (usually greater than 6 to 6.5 cms) and one wants to either maintain their existing forehead length or advance or lower the frontal hairline to to shorten their forehead height. The pretrichial incisional length would be shorter than the coronal incision (because it it closer to the brow) and there is less risk of any significant scalp numbness.
The scars from either the coronal or pretrichial incision usually heal well as evidenced on my experience of very few scalp/hairline scar revision ever requested. Quite surprisingly, even though the frontal hairline incision is more ‘exposed’, it actually heals very well as hair eventually grows through it. As a result, many brow bone reduction particularly in the transgender patients, use a pretrichial incision. This is also useful as hairline advancements, brow lifts and upper forehead augmentations (to create greater forehead convexity) are often aesthetically advantageous and simultaneously done.
Recovery from brow bone reductions is very similar to that of an open brow lift. It is all about how much swelling one gets around the eyes and how long it takes to go away until looks socially acceptable. That is usually about ten days.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a mouth widening surgery procedure.I have a VERY small mouth. It is of equal width of my nose (my nose is thin). I have read your concerns about post surgery scarring with this procedure and I think that for me personally, the benefits tremendously outweigh the risks. But I guess that’s for you to decide. I just have a couple of questions though first. How prominent are the scars? And can they be removed through either permanent makeup or steroid injections? I read that you said this procedure is easy. Please contact me when you can because your one of the only surgeons who is qualified enough to perform this. Thanks!!
A: A mouth widening surgery procedure (opening commissuroplasty) is a limited procedure and not difficult to undergo given that the corners of the mouth are small in size. The fine line scars are placed at the junction of the skin and vermilion around the corners of the mouth. Should the scars heal unfavorably, they will not be effectively treated by steroid injections or makeup, they will require re-excision and closure. (surgical scar revision) You should not think of scars being ‘removed’, they can be reduced but never completely removed. You are correct in your assumption that one’s mouth width (corner to corner) should exceed the width of the lateral ala when vertical lines are dropped down past the mouth. By ideal proportion standards, the width of the mouth should be 1.618 that of the width of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had plastic surgery done nearly 4 years ago that has left me what I consider deformed. I don’t resemble myself and there were so many mistakes the doctor made to my face. I am deeply saddened and depressed over this not only because of the cost but that I’m left disfigured and violated. I had my nose done where the doctor inserted a silicone implant promising that he would be able to correct my slight deviation with it. That was not achieved and my nose appears even more deviated, my nose looks short, and my nostrils more visible. I have thin skin so I feel you can almost make out the implant when looking at me. I would very much like to correct the mentioned issues. Also he performed an extraoral jaw reduction on me that left me further disfigured. He overcorrected and now my face has the appearance of a horse. I would like to restore the lost volume and give my face back it’s natural contour. Not to mention the incisional scar is very unsightly. It’s almost two inches long and is hypertrophic and red. I would like to revise the scar to make it less noticeable. I also had a silicone chin implant placed but it does not fit my face. It’s too big and wide and I would just like it removed and possibly have fat grafting to that area instead. I would possibly like other areas to be fat grafted as well such as my nasolabial fold and the hollows of my eyes.
A: From a nose standpoint, if you had an initial nasal deviation overlaying silicone implant on a nose that is deviated will actually make the nasal deviation look worse not better. So your outcome is not a surprise since you have to lay the implant on the existing nasal base. With thin skin and implant encapsulation, implant visibility often appears years later. From a short nose and nostril visibility standpoint, I am not sure how an implant would have caused that per se with the exception of a high bridge and dorsal line may make the amount of tip projection/rotation perceptibly look shorter and more rotated. From a secondary rhinoplasty correction standpoint, it appears that the implant would need to be removed and cartilage grafting done to augment and lengthen the nose with tip derogation as well as correction of the underlying nasal deviation which almost certainly has a septal deviation as a core root of the problem. The question is where the cartilage needs to be harvested from and that would depend on how much is needed. The debate is always whether it would be a combined septal/ear donor site or whether more is needed which requires rib cartilage. I would need to see some side view pictures to have a better idea in that regard.
From your prior jaw reduction procedure, I am assuming that the incisions and now red scars are at the back of the jaw behind the angles. (a side view picture would show that better) When you say you have lost volume and has changed you facial appearance (I don’t know if I would go so far as calling it horse-like), that likely implies that it looks too long because of the lost jaw angle volume and a steeper mandibular plane angle. (high in back and steeply slopes downward towards the chin) Restoring lost volume from prior jaw reduction in my experience is done by adding a jawline implant closer to the lost angle area to add some vertical length and a little bit of width.
Revisions of the jaw angle reduction scars can certainly be done and would likely result in a better outcome since they would not have the original traction. (pulling and stretching the skin to cut the bone) The interesting question about your scars is whether that access should be used for the placement of the implants since you have them already. That would make your recovery much easier than from gong inside the mouth. Whether the implants can be used forms standard stock sizes or should be custom made from a 3D CT scan is another issue to debate.
One of the may problems with chin implants done in women is that they are are often too wide as extended anatomic styles are often used. The question here is whether it should be replaced with a smaller central button style chin implant (which is far more appropriate for female faces) or replace with a fat graft with its unknown survival rate.
Lastly, fat grafting can be done for the nasolabial folds and eye hollows with the only real issue bend their survival is the risk of some unevenness or lumpiness in the eye hollow area due to the thin skin. This can usually be minimized by using a micronized fat grafting technique where the fat particles are made very small before injecting.
I hope these comments are helpful and if you can send some side view pictures that would be useful for further analysis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel that I have a slightly vertically long chin and a prominent jawline. My chin lengthens when I smile. From my profile however, my chin does not seem to have much projection and is slightly receding. A year ago I had a jawline and chin contour but I feel my results are minimal at best. I am consulting with you because I am looking for an expert opinion and what realistically can be done.
A: Often in chins that are retrusive, they are also vertically long because of the backward rotation of the entire mandible. (jaw) This would account for your chin lengthening when you smile but yet it looking too short in profile. I don’t know what type of chin and jawline contouring you had done but I would think your issue is improveable by a ‘redistribution’ issue as opposed to a completely reduction approach. (taking away bone with this nine shape would likely produce no substantial change in its appearance) It would seem that if your chin bone is brought forward and vertically shortened at the same time (angled sliding genioplasty) that would be the correct bony reshaping needed to address what the problem really is. I would envision no more than a 5mm chin advancement but a 5mm vertical shortening as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like I have a good bone structure but my jawline and lower face shape is hidden by excess fat. Will a buccal lipectomy get rid of the fat above my jawline and chin or would it get rid of the fat below the hollows of my cheek bones? I ask this because I know this procedure can create a hollowed skeletal/meth-head look and having very high cheekbones, I know I may be prone to this effect. I am 20 years old.. Though this procedure is generally for older people, do you think it would benefit me by outlining the contours of my lower face? I would like an estimate and maybe an opinion on the procedure if you can spare one. Thank you for your time 🙂
A: When it comes to a buccal lipectomy, it is important that one distinguish what it can and can not do. It can reduce some fullness right below the cheekbone which you can locate by placing your thumb on the underside of the cheekbone. As you can see by doing this, that will not affect any fullness below it near the mouth or the jawline. This is an area that I commonly treat with small cannula liposuction to reduce the fullness in this area. This procedure has no risk of ‘overskeletonizing’ the face as it is subcutaneous fat removal and not one large lump or ball of fat like that of the buccal fat. (actually if done properly and in a subtotal fashion a buccal lipectomy will not make the face too hollow)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking an ‘enhanced’ cheek dimple surgery. I already have one existing dimple on my right cheek. Can cheek dimple surgery enhance it and make it more prominent?
A: An existing cheek dimple already has the anatomic features that make it visible, an underlying defect in the buccinator muscle and a tethering of the skin down towards it. To enhance an existing cheek dimple (make it deeper and more pronounced) it is just a matter of removing some tissue between the dimple skin and the underlying muscle and placing a percutaneous suture to bring the skin further in to make it more deeper or more indented. This is a procedure that can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested on finding out if a browlift I had done can be reversed or a brow lower ing procedure be done. About one year ago I had an aggressive endoscopic browlift done in which afterwards has lifted my eyebrows way too high. I only had a minor brow sagging problem beforehand and was borderline for the procedure anyway. My surgeon told me they would eventually drop but have not done so and if they have it is clearly not enough. I look like the proverbial ‘deer in the headlights’ look compared to what I looked like before surgery. Can this overdone browlift be fixed in your experience?
A: Excessive brow elevation from an from an overdone browlift can be treated by observation for 3 to 6 months or a brow lowering procedure. Most overlifted brows will usually relax to an acceptable level. But if not, a brow lowering procedure can be done with a subgaleal dissection release combined with an intraoperative tissue expansion manuever. Using a small tissue expander placed in the mid-forehead, it is inflated to its maximum volume to aid with the subgaleal release. Done together, a browlift can be reversed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am about two months after double jaw surgery and sliding genioplasty to correct an open bite and weak chin. Everything is healing nicely, however since day one of my genioplasty, I have noticed that when I raise my lower lip or close my mouth, there is a “shelf” that forms from the mentalis muscle pushing up. It looks like a very deep labiomental fold, however it protrudes enough for me to be able to literally grab onto the muscle that is sticking out. This has been causing me to be tremendously depressed to the point where I’ve gone back to my surgeon and requested a revearsal of the genioplasty. I’ve been hearing about ptosis problems associated with chin augmentations, however mine seems to be the opposite. It looks fine with my mouth is open, however when closed, the muscle seems to be contracted too much and pushing out of my face. All of the doctors I’ve seen at my surgeon’s office seem to think that it will resolve with time, and that the incisions need to mature before the muscles can fully relax. However, it hasn’t shown any improvement. I was told if it doesn’t resolve by April, then it can be addressed, although I hate to wait that long. What I want to know is, what exactly is causing this, what is it, and by which method can it be fixed?
A: In a sliding genioplasty, the chin bone is brought forward and brings with it all of the attached soft tissue. Depending upon the angle of the bone cut of the genioplasty, the amount of bony advancement, the shape of the chin soft tissue pad before surgery, and how the mentalis muscle was sewn back will all influence how the chin soft tissue pad now looks and moves. What you are describing and demonstrating in your picture is a dynamic muscular deformity of the chin pad. (a roll becomes present when smiling, OK at rest) What I would do is first have some Botox injections done into this chin roll to determine if this is aesthetically helpful. If it improves with Botox then it becomes a later question of a mentalis muscle release and repositioning. (this also buys you some time without having the chin pad deformity as well ) If it does not improve with Botox injections then the only improvement is going to come from undoing the genioplasty to some degree. The interesting question in this regards is how much did the chin bone move forward and as it vertically shortened at the same time. In larger sliding genioplasty movements, the chin bone may come forward but may also get vertically shorter. This may cause some soft tissue bunching when one smiles as there is now an ‘excess’ of tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial liposuction. I am slim but hate my chubby cheeks. Whatever I do they don’t go away. I tried buccal fat removal with little luck. Problem is the round bit of fat in malar pads which always goes very high on my apples of my cheeks when I smile. Can the cheek malar pads be removed completely? I want like male models so it looks like no fat at all on cheeks and so When smile it is just skin that raises up instead of the fat malar pad. I dont need malar lift, I just want it to be gotten rid of for good. Can it be completely removed and sucked out even if this may leave some sagginess of the skin. After that maybe I can have midfacelift if needed but I really want this malar pad gone. It is not buccal fat that I want gone, it is malar pad which rests on top of cheekbone. I don’t want a malar lift to redistribute fat on to higher position, just complete removal. Is it possible?
A: I understand perfectly as to what you are referring to and it is no surprise that a buccal lipectomy would have no effect. The buccal fat pad is in a lower anatomic location. The tissues that you are referring to are over the malar region but to describe them as the malar ‘fat pad’ is not anatomically accurate for what you are trying to achieve. The malar ‘fat pad’ is not like the buccal fat pad, it is not an isolated and thus easily extractable type of fat. Rather it is fat mixed in with other tissues giving it a more fibrofatty quality to it. Thus it is not amenable to excision (like the buccal fat pad) and is more resistant to small cannula or microliposuction. This does not mean it can not be treated, it is just a question of how effective it would be and that disrupting these tissues will cause it to sag as the suspensory ligaments would be traumatized. But when it comes to complete removal of the malar fat pad fullness, I do not believe that is surgically possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need some skin care advice. I was using both Task Essential Serum Revitalisant 02, 02 Revitalizing Serum in the morning, Task Essential Treatment Regenateur 02,and 02 Regenerative Treatment at night. After my operation, switched to Cetaphil. Do you think Task Essential are the best products to use? And is Task Essential New Skin Exfoliant the best scrub to use on my face? Also is Task Essential Pure Mask Instant the best mask to use on my face? And what is the best sunblock to use for my skin? By-the-way, when I use Cetaphil Cream on my face, should I use a lot. And should I use a lot on my nose and instead of rubbing it into my skin should I let sit sit on my nose overnight?
A: When it comes to skin care products, there are literally thousands of product options. In reality there is no one single product or product line that is the ‘best’ or is the best for anyone. Probably hundreds of these thousands of product options would be effective for most people. What is important about any facial skin care product line is that one finds it non-irritating and comfortable to one’s skin as the benefits of any topical skin treatment is based on regular and sustained use. In short, neither of the two products you have chose is better than the other. Use the one you like the best.
The same issue applies to sunblock. Most moisturizers today contain sunblock and as along as it is at least SPF 30 in strength that is all that matters.
Your goal with any skin care product application is to use the least that works. Using more does not make it more effective, that only allows you to go through more product faster.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of breast implant replacements. I had breast augmentation in 1991 and it appears one of my implants must have ruptured and has deflated. I need to explore my options.The original surgery was done by using implants with a silicone shell with outer saline fluid.
A: Your original breast implants by description were what was known as Becker implants. They were a double lumen ( 2 bags) implant with an inner bag that contained silicone and an outer bag that contained saline fluid that was filled at the time of surgery. The logic of that old style breast implant was that it helped control silicone gel ‘bleed’ which had a known effect of causing high rates of capsular contracture at the time. (breast implant hardening) Those implants have not been manufactured for over 20 years although some few patients still exist with them in. Like a completely saline-filled breast implants, rupture and partial deflation (remember there js still an inner bag that has intact silicone gel) was inevitable. Getting 23 years of service out of these breast implants means you have done well. This day was eventually coming and it now appears that it is here. The only real significant question with breast implant replacements is whether you want to go with a completely saline-filled or silicone gel type breast implant and whether you want a similar size in volume with these replacements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal implants but I have a twist to my need. I am bald and can’t regrow hair so I keep my head shaved. In addition I had a direct browlift last year so there are healed incisions right above my eyebrows. My question is can these implants be placed by going through the brow incisions? I hate that I would need temporal scalp incisions which would be very visible in someone like me.
A: While temporal implants may be aesthetically beneficial for you the question is how to get them in there in a ‘scarless’ manner in someone who shaves their head. This is a unique male question and not one that is seen in females. As you have read, the approach for temporal implants is from a 3 to 4cm incision just above the ear. While that approach makes it very easy and simple to do, the concept of a fine line scar in shaven scalp skin does give me pause. Your question of whether a temporal implant can be placed through a direct brow lift incision is an interesting one and the presence of a scar in that area poses a unique ‘opportunity’. The eyebrow incision for temporal implants is one I have never done and I doubt if it has ever been done anywhere in the world to date. By its proximity your eyebrow scars provide direct access to the area of temporal hollowing but the attachment of the temporal fascia to the lateral orbital bone is quite stout and would have to be released to gain entrance to the subfascial temporal plane. (having done a lot of craniofacial surgery I am very familiar with doing surgery in this area) The simple answer to your question is that it is theoretically possible and if one was doing some adjustment of your direct brow lift anyway there is no reason not to try. If it becomes too difficult to do, one can always then switch to doing fat injection into the muscle and on top of the fascia to create a temporal augmentation effect.
Dr. Barry Eppley
Indianapolis, Indiana
