Your Questions

Q: Dr. Eppley, I am interested in a breast reduction but my situation is a bit unusual. I currently have breast implants but gained weight after surgery with my third child. That was over ten years ago. I would like a breast reduction with my implants removed. I do not want to be bigger than B cup… I am currently a D/DD cup.

A: With breast implant removal and some significant breast tissue on top of them, a full breast lift may be likely needed. Due to concerns about blood supply to the nipples, the amount of breast reduction/lift that can be done may be more limited than going all the way down to a B cup may permit. Conversely, based on the size of your existing indwelling implants and their location (submuscular vs. subglandular), such a breast size reduction may be very possible. Larger breast implants that are in a submuscular position will safely permit more of a breast reduction/lift. I would need to see pictures of your breasts to help make that determination.

Removal of breast implants by itself causes an obvious breast reduction effect. But the now excess and potentially sagging overlying breast tissue must be managed to create a smaller and tighter breast mound.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead recontouring but all of your case studies of the procedure show people with hair. I can see how an incision made for forehead recontouring along the hairline is great if you have hair and can hide the incision. But what if you don’t have hair, how would you handle that?

A: There is a reason you do not see pictures of almost any kind of forehead recontouring procedures in men who either do not have hair or have a shaved head…they do not do the surgery. The scar would not be a good tradeoff in the vast majority of men unless the forehead deformity is very noticeable or extreme. Having said that, I have done a handful of men who have no hair for forehead recontouring but they are extremely motivated and are willing to make the aesthetic tradeoff of a scalp scar.

In some cases of forehead recontouring a forehead incision through a prominent wrinkle line can be considered as an alternative to a scalp incision. This can be a more ‘natural’ and direct approach based on the age of the patient and the extent and depth of the forehead wrinkles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: D. Eppley, I need advice on a facelift result. I am a 63 year old female, who has lost 125 lbs from gastric bypass surgery over two years ago and had a facelift done two months ago. Sadly, my neck wattle has partially returned and both I and my plastic surgeon are very disappointed. In reading my operative note the facelift technique done was a lower facelift/corset platysmaplasty, lateral spanning sutures in platysma, and SMAS plication, with extremely wide skin undermining.
 
I am at a loss of what I or my plastic surgeon could have done differently! I don’t want to go back to surgery with the same plan which has already failed once. My plastic surgeon suggested the option of a direct neck lift but I don’t want the visible scar.
 
Do you have any experience with facelift surgery in massive weight loss patients?  Was I asking too much from this operation? I know my skin elasticity is terrible and there is some improvement but not a lot.

A: In my facelift experience with large neck wattle in extreme weight loss patients, the first thing I tell them is that their degree of neck laxity may require a secondary procedure due to rebound relaxation and an inability to adequately reposition all the neck skin up and back. What looks good on the operating room table may be inadequate or does not always hold up well. So plan the surgery as if it is a two-stage procedure.

The second issue is what I do during surgery…you will need a major back cut behind the ears that either extends well into the occipital hairline or goes along the occipital hairline down very low into the posterior neck. This is the only way you can find a place to redrape the neck skin and excise it. In necks like these it is all about incisional location and it is different than a more traditional facelift. This also applies to the anterior incision as well. Because so much skin is being moved, and I don’t want the preauricular tuft of hair to end up way above the ear, I do a blocking incision technique. This is where the incision is made not up into the temporal hairline but around the preauricular hair tuft in a Z-shaped pattern. Good mobilization and redraping of the skin with these incision patterns, will show intraoeratively that the entire ear is completely covered before you make pilot cuts and skin excision. If it is not, then the amount of neck skin redraping will be inadequate.

I would simply plan on doing a secondary facelift with these modified anterior and poster incision locations, doing skin only, and it will be much better than the first time. The reality is that this type of neck skin excess and poor elasticity defies a traditional facelift approach.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a severe tear trough deformity and am interested in the implant procedure. However there does not seem to be anyone in my area that will use implants for correction????

A: Thank you for your inquiry and seconding your picture. I think you are referring to a complete infraorbital rim implant not just a tear trough implant which just covers the inner half of the orbital tim. While most plastic surgeons prefer fat injection grafting for a deficient infraorbital rim, I prefer an implant rim augmentation technique which produces a more reliable, smooth and permanent result. This is a vey rare type of facial implant that is used only by experienced facial implant surgeons. While the technique to place them is the same (lower eyelid incision), the design of the infraorbital rim implant varies. It can be made as a custom implant from the patient’s 3D CT scan or can be used as a ‘semi-custom’ type implant which is a derivative from prior custom implant patients. (infraorbital rim anatomy/shape is not that different amongst most patients) There are no performed or standard off-the-shelf infraorbital rim implants for use…which is also why there are so few surgeons that use or have any knowledge about them.

When in doubt about using infraorbital rim implants, one should always try fat grafting first. There usually is little to lose by doing so as fat often completely resorbs in the infraorbital area. If it is overdone and too much fat persists then infraorbital rim implants can be placed and the extra fat removed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting my chin dimple. My chin really bothers me the most right now. Once we meet in person I think it will be easier to assess. I have researched for two years now the options to get rid of the dimple in the chin. I have read a lot about the injectable fillers to achieve a temporary fix, so again once we meet in person you can tell me what you think about that option. Anyways, attached are pictures where you can see the dimple a little bit. Pictures do not do it justice though! Attached you’ll see a recent pic I took where you can see the dimple. Also attached you will see a side profile where you can see the dimple in my chin and also the tip of my nose that irritates me! Thanks for your help! 

A: Thank you for sending your pictures. What you have is really bit of a vertical chin cleft which you are calling a chin dimple. Those can be difficult to treat effectively. The simplest and the best injectable filler treatment is either fat injections or micro droplet silicone oil. (which is permanent) If you were having other types of surgery then fat injections would be worthwhile since you are already there. Otherwise you can try injectable fillers in the office and see how effective it is first before doing something permanent like silicone oil.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip reconstruction. Attached are photos of my lips.  Two years ago, I had a vermillion lip advancement. However, the surgeon did a v/y to the central portion of my upper lip…something that was never discussed beforehand.  I’m left with no cupid’s bow and no philtrum.  My lower lip hangs down and there are ‘pouches’ just below the lower lip. What can you do to make my mouth look better, and most of important, what can be done to lift my lower lip so that my teeth don’t show and those pouches diminished. Thank you so much in advance. 

A: Thank you for sending your lip pictures. Lip reconstruction efforts can be done on both the upper and lower lips. Certainly the upper lip vermilion advancement can be improved because that is straightforward redesign of the shape of the upper lip and advancing the vermilion edges according to the new pattern cut out. This is very predictable and will make a positive improvement. Raising the lower lip, however, is considerably more challenging, not easy, and very unpredictable. Regardless of the dubious success of raising the lower lip, the pooches that lie below and beyond the vermilion of the lower lip can not be improved. Techniques to try and raise the lower lip usually require a sling or suspension of tissue placed across the lower lip from one mouth corner to the other. (technically from a small incision at the end of each nasolabial fold crease to the sling can be threaded through) This sling could be comprised of your own tissue (abdominal fascia) or an allogeneic (cadaveric) sling of dermis can be used. (e.g., Alloderm)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?

A: Thank you for sending your pictures. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullness below the cheek bone which does not work well in your face. I would recommend the following:

1) Remove existing submalar cheek implants.

2) Your new cheek implant style would be any form of a combo or one that has any submalar component at all.

3) You need ‘high’ malaria augmentation  styles implant that also go back further onto the zygomatiuc arch. No such standard malar cheek implants exists, even amongst the standard malaria options. Ideally a custom cheek implant style is made that would fir your face precisely and create the augmentation exactly where it is needed. because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.

4) If I was ‘forced’ to use a standard cheek implant I would the malar shell style and modify it during surgery.

5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a gastric bypass surgery three years ago to lose weight. I have lost nearly 200 pounds. I am a 50 year-old female. My primary insurance is Medicare and my secondary is Champ VA. i did not have to pay a penny for my gastric bypass. I saw a story on my local news tonight about Cool Sculpting. A procedure that costs $1,500. by a doctor in California. One place locally here has given me a quote of $7,600 tor a tummy tuck, but there is no way I’ll ever be able to save that much money. I have no credit cards. I don’t even have a car or a phone. I cannot afford a monthly payment on a car much less the insurance. Nor can I afford a monthly payment on a phone. My car broke down last year with a cracked engine in January. I rent a car when I need to go out of town. Thank you.

A: When one has lost 200 lbs, the overall circumferential body problem is too much skin. Do not waste your time and money on anything other than a major tummy tuck operation. There is nothing less than a big operation to cut out the extra tissues that will work. You may have luck finding a plastic surgeon who takes Medicare to do your surgery (which is very scarce) or you may be able to have it done in a VA. But other than these unlikely options, being able to do a tummy tuck like you would undoubtably need at just $7,600 is a bargain. Whomever offered to do your surgery at that very low rate for a tummy tuck like you would need was doing you a major favor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty done two months ago and I think that it has shifted. I am not sure if there is a gap on part of it because of the shift. I would like your opinion and evaluation. 

A: Thank you for your inquiry. I understand that you think your sliding genioplasty has shifted. Did you have any x-rays after surgery or any now that would help understand if that is what has happened? It is also possible that as all the swelling has finally subsided any asymmetries can become more apparent which are masked for the first 4 to 6 weeks after surgery due to the swelling. Please send me some pictures or anything that shows where you see the chin/jawline asymmetry. It is also more likely than not that the gap you see is the step-off at the tail end of the sliding genioplasty along the jawline behind the chin. This can be more apparent on one side or the other and is more common if the sliding genioplasty movement was significant or the angle of the bone was at least 45 degrees or greater. The bigger the bony movement and the greater the angle of the bone cut, the more likely jawline indentations will appear after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty and jaw recontouring (after I had upper and lower jaw surgery previously with a different doctor). After the sliding genioplasty and jaw recontouring my chin still wasn’t in the middle and I am unhappy with the shape of my jawline,. It seems to have a lot of dents after the surgery (see the before and after x-rays). Is it normal after jaw recontouring and sliding genioplasty to have this kind of irregularities and is it possible to get more symmetry? I hope you can help me with these questions.

A: Thank you for your inquiry and sending your x-rays. What I can see on the x-rays is that the left jawline looks very irregular from the chin on back to the jaw angle and has clearly been surgically manipulated. Curiously the right side of the jawline looks fairly pristine…almost as if it has never had surgery at all. I can not appreciate the chin asymmetry as the x-rays shows a bony chin that looks midline. The left lower border looks a little irregular. How this correlates to what you look like on the outside would be relevant to whether and want you should do next. In looking at your pictures of your past jaw recontouring efforts, you look just like your x-rays with a very irregular left jawline and chin asymmetry. I would recommend you get a 3D CT scan from which a custom inferior border implant that would extend from the chin back to the jaw angle to improve your jawline and chin asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been considering a breast augmentation but I have a few questions. I’m 21, and I’ve read that you cannot do silicone breast implants until you are 22. I’ve also read that it’s illegal to get silicone done under 22, but I’m not wanting to do saline. I’m curious if it’s possible to do silicone or not at my age. If it’s not how does that work. thank you for your time!

A: Let me provide clarification about age and the insertion of silicone breast implants. Because the long and extensive clinical trials for the silicone breast implants used today consisted largely of women between the ages of 22 and 65 years of age, the FDA listed that age range as the recommended ages of silicone breast augmentation. While that is the FDA guidelines for the use of silicone breast implants, it is completely up to the plastic surgeon to use them as he/she sees medically appropriate. Thus it is perfectly legal and medically appropriate to use silicone breast implants at any age below 22 years old. This is up to the decision and informed discussion between the plastic surgeon and the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a septorhinoplasty procedure. I previously have undergone balloon sinus surgery in order to correct breathing issues. I have been to an ENT doctor and he suggested further reduction of the turbinates. I also have a problem with the sides of my nose collapsing when I breath in heavily. I wanted to correct the breathing problems especially because my chosen career is very physically based, as well as reduce a bump on my nose. I am very interested in if you would have any additional things to add to aid my breathing as well as improve the appearance for my nose. 

A: Having not seen any pictures on your nose or examined you, I can only make some speculative opinions based on your description of your nasal symptoms. While further reduction of your inferior turbinates may improve your breathing, collapse of the nasal sidewalls with inspiration suggests weakness of the lower alar cartilages and impingement of the internal nasal valves. Such nasal valve collapse can cause greater breathing difficulties than a mechanical obstruction of the inferior turbinates. Since you interested in taking down your existing nasal hump as part of a cosmetic change to your nose, the incorporation of middle vault spreaders to open up and stabilize the internal nasal valves as well as batten grafts to support the lower alar cartilages would be adjunctive nasal airway maneuvers in addition to the inferior turbinate reductions. This more comprehensive approach to your septorhinoplasty should provide some significant breathing improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in pectoral implants. I had gynecomastia reduction done twice in the last 10 years. I still have divets because I think too much tissue was removed on the outside areas of my pecs. I am also considering pectoral implants to even this out and provide a more contoured even look. I work out often and I still am not able to get my pecs looking good. I have read about your expertise with male cosmetic enhancements.

A: It sounds and looks like the combination of pectoral implants combined with some fat grafting to the nipple-areolar divots would create a more contoured chest result. It is hard to argue with the immediate and dramatic improvement in chest shape that pectoral implants can create. But they alone would not fix any indentations from over resection from gynecomastia surgery. That will need to be addressed directly with fat grafts put right into the soft tissue defects.

Gynecomastia reduction, particularly if done by liposuction, can often leave the chest looking deflated particularly in older men. Pectoral implants can make for an instant change in chest size through muscle enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a jawline implant I am a 50 year old male in good shape. I had liposuction under my chin for the first time at age 35. About ten years ago I had a neck lift and liposuction under my chin. At 50 years of age, I am interested in a Jawline implant and tightening of the platysma muscles which seem to be sagging. Additionally, the skin under my neck is just a bit saggy. I would like a 90 degree cervico-mental angle, similar to Rob Lowe without the protruding chin. I would rather get this done while I am younger so it won’t look so dramatic after the surgery? Can anyone tell that one has had jaw implants?

A: I need to know whether you mean jaw angle implants or a total jawline implant. I believe you may be referring to a total wrap around jawline implant which can be combined with a submentoplasty procedure for the optimal jawline-neck shape change. Such jaw implants are not detectable unless they are overdone or look obviously disproportionate to the rest of the face. They require a preoperative 3D Ct scan for their custom fabrication.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in alar base repositioning. I read in a Real Self post you commented on regarding a lady who had one ala that was higher than the other side. You mentioned that you can lower the high alar sidewall through a simple technique. I have the same issue: my left ala is higher than the right, so my nasal sills/base seems it slants up toward the high side, my supra alar crease is 2-3 mm higher as well, and my upper lip also follows this upward slant. I have slight form of hemifacial microsomia where the left side of my face is smaller (and shorter) and less full than the right. Can you tell me what this alar repositioning technique is? How do you lower the higher alar side? I consulted with my local plastic surgeon and he considered an anchor suture technique to try and pull down the high side. The problem is, I had a prior surgery where a different surgeon put a Medpor implant (with screw) in my pyriform aperture and there is a screw there. My current plastic surgeon said he would need to put a screw for the anchor where that screw is currently in for the implant. Was the anchor suture method the method you spoke of in that lady’s post? Can the Medpor implant that I have be removed? And can the anchor be put in its place, using the same screw hole to fasten it? 

Just thought I’d ask because you’re the only plastic surgeon that has also mentioned this technique to lower an alar sidewall that is a higher than the other side. You also mentioned in another post of using this method to raise the ala (the opposite), has this been successful? I’d appreciate your advice and information on which technique you were referring to, in order to lower or pull down one alar sidewall that is higher than the other side. I would like to have my higher ala/nasal sill, and upper lip lowered for better symmetry. It seems that when I pull the skin down next to my supra alar crease, everything else goes down with it, and it looks more symmetrical, how I want it. I have yet to find a doctor who can actually do all this, as my asymmetry is due to my facial bones. It sounds like the anchor suture thing would be the thing to do, but then again, I am not a Dr. by any means, so I wanted to ask you since you mentioned a technique to the lady who has the same problem I have. 

A: There are two basic ways to lower a higher ala (alar base repositioning), either a skin excision alarplasty or a suture anchor fixation method to the underlying pyriform aperture. I would need to see pictures of your face to determine which may be more appropriate. Your indwelling Medpor implant does not pose a problem for the internal anchor technique. The implant can be maintained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had sliding genioplasty surgery couple of days ago and moved forward 8-9mm.I hate my bottom lip got 1/4 size of my original one! It’s a heart attack and I loved my lips! Did you see any improvement in lip’s size after a while? Should I reverse the surgery?Attached are some picture of before and after 4days surgery. I really liked my bottom lip and I feel the suture are tok high that locked my lower lip and I doubt if it loose even after it heals. The reason might be because of the 8-9mm projection on my chin or the surgent personal desire to balance my lower lip without letting me know in advance. As I know he moved my chin 8mm out and little down. Now I can’t accept new round face and nice bottom lips are gone! What I wanted to have was a little projection!  What do you recommend? I am thinking to revise partially before my bone get heal! Although I am worry because it might not give my pervious face and lips back! So appreciated for the help.

A: Thank you for sending your before and after sliding genioplasty pictures. I think it is extremely important to realize that you are just 4 days after surgery and the chin always gets tremendous swelling…which is why your face seems round right now. That will change over the next three weeks as some of the swelling subsides. I see no evidence that your chin is ‘overdone’ or been advanced too far. I think from an augmentation standpoint that you should wait much longer as it takes a good 6 weeks to really appreciate the final result. As for the your lower lip, it is very common that it feels very tight. This will always loosen up much more than it is now.

I think right now you are going through ‘buyer’s regret’ which is not uncommon with all the swelling and tightness and the uncertainty of what will be the final outcome. It is not rare that one yearns for what they look like previously when going through the early recovery period after many forms of facial structural surgery such as a sliding genioplasty.

I would urge you at this point to have more patience and give it two to three more weeks to see how you feel then. The osteotomy can be easily partially or fully reversed even months after the initial surgery date.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wanting to have jaw angle reduction to make the face slimmer.

1.Is it correct that if the jaw angles get cut; then the periosteum that covers the jaw angles will also get detached or cut, correct?

2. The “standard “ jaw reduction surgery would ensure that the periosteum is intact to the jaw bone throughout  the procedure. Not to cut the jaw angles which will also result in loss of shape and bone support. Therefore it is best to do a sagittal reduction to make the jaw slimmer?

3. For the sagittal reduction, does it mean that the periosteum does not get detached? I read that a standard procedure would be to keep the periosteum intact and have a sagittal reduction, not cut the jaw angles ? But I don’t understand why the periosteum does not get detached in a sagittal reduction?)

A: The periosteum must be elevated (detached) from the bone in any jaw angle (mandibular ramus) procedure. That is not what is important in preventing soft tissue sag after jaw reduction surgery. The relevant issue is the preservation of the bone angle shape. A traditional jaw angle reduction obliquely removes the full thickness of the angle where various ligaments attach. It will dramatically make the width of the angle less but do so at the loss of angular shape and potentially soft tissue support. The sagittal reduction method preserves the angular shape and soft tissue support although the width reduction will be less.

Either jaw angle reduction technique has its place. It depends on the natural jaw angle shape and thickness of each patien and what one is aesthetically trying to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about rhinoplasty and how it it planned and performed. How do cosmetic surgeons measure the profile of the face? From where to where? Is there a ratio that is considered perfect? Was it derived from the great medieval sculptors?

A: Contrary to popular perception, plastic surgeons do not use specific anthropometric measurements in planning and subsequently performing rhinoplasty surgery. While there are many known angle and measurements of the nose, and plastic surgeons are well aware of them, they are only roughly applied in performing the procedure. Surgeons use a gestalt about these anthropometric values and measurements rather than a precise application of them. Plastic surgeon may learn these measurements in their training or through experience but they do not use such precise measurements in surgery. This is because actual surgery does not translate well to afew millimeters or degrees of angulation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I originally sought rhinoplasty due to great discomfort concerning the projection of my nose.  The tip feels enlarged and out of proportion to the rest of my face as well as deviating to one side.  However, after speaking with a surgeon, I have come to learn that my jaw is retrusive which makes my nose look larger.  I would like to know whether or not you think I would benefit from both jaw and rhinoplasty surgery, or whether you think one or the other would be enough to balance my face.  I have attached some photographs in this email.

A: Thank you for sending your pictures. I think it is quite clear that in looking at them that the short chin/jaw is a far greater contributor to your profile concerns than that of the nose. Like many profile concerns, it is really a ratio of the nose:chin in looking at the deficiency and where the greatest improvement may come from what procedure. In your case I would put it at 80:20, jaw:chin. While chin augmentation will make a major difference, a rhinoplasty where the tip is thinned and a bit shortened will make for an even better result.

In many cases of rhinoplasty, the chin augmentation that may be done with it is complementary to the nose changes. But in your case it is the reverse…the rhinoplasty would be complementary to the chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting you in order to get some information on my recent zygomatic reconstruction. I had zygomatic bone (whole complex) reposition after overlooked fracture. The bone healed in wrong position and it had to be cut then repositioned. CAS (computer assisted surgery) was performed. 

It’s 5 weeks since surgery and my masseter muscle looks strange when I open my mouth. I wonder why ? My surgeon only says me “wait, wait it will go away”. There is 0% of improvement. I’m not sure if the problem its gonna resolve itself.  I’m afraid of TMJ since this muscle works improperly now. I feel some restriction in my occlusion (mouth opening) but not big. I can eat normally with little discomfort. My occlusion amplitude is about 3cm. Before surgery I had about 4cm. I realized that after fracture I didn’t have such problem because the displaced bone adjusted to muscles. Hence they were working perfectly.

IMPORTANT: After surgery new position is forced. My logic thinking says me, there may be not proper angle and eventually “distance between 2 parts of zygomatic arch, what gives strange position for different parts of masseter muscle. I never had symmetry .. I wonder what if my surgeon was focused too much on symmetry and set the bone in the position very uncomfortable for my muscles. What if waiting will not help and it’s gonna stay like this and some irreversible complications will occur. 

Is it due to wrong position of the zygoma bone including zygomatic arch ? 

swelling.? I do not see swelling there. I have mostly little swelling on the cheek, but no on the side of the face near the muscle Too big change ? Muscle need more time to adjust ?

A: Thank you for your inquiry and sending your pictures. As I interpret your current situation, you have a right zygomatic osteotomy done about 5 weeks for an initial displaced ZMC fracture. Your current symptoms are that of some persistent limited oral opening and right facial masseter ‘asymmetry’. As a general statement at this point after this major facial surgery, what you are experiencing is very common and expected. It will take you a full six months to achieve a full recovery…and this includes to have all of the facial swelling to go away. (I believe the masseter muscle/facial asymmetry you are seeing is still some swelling) At the least five weeks after surgery is not a complete resolution time for all facial swelling to go away.

I would also expect you to not have complete normal oral range of opening just yet. You should certainly begin oral range of motion exercises at this point to workout the muscle stiffness and increase the amount of opening that will be comfortable=y achieved. It will take a full three months to get back the normal range of interincisal opening. You didn’t have these symptoms after the injury because all of the masseter muscle attachments to the zygoma were not disrupted, but to reposition the zygomatic bone some of them must be. The reconstruction effort causes greater internal trauma to the area than that of the original injury.

Such zygomatic reconstruction is always done based on ideal bone positioning. It is never done based on any consideration for the exposure and partial release of a few anterior attachments of the masseter muscle that are needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. How many ribs can a patient have removed all together? I’ve read about your procedure and I would like more ribs removed, rather than just: 10, 11, or 12. I have very strong, prominent, wide ribs that I no longer wish to have. Wearing tight jackets and tight tops make my appearance look much worst. Can you remove more ribs than just these six? What is the cost of this surgery?? 

A: The main purpose of rib removal surgery in most cases is to narrow the waistline. Ribs #10, 11 , and 12 are the only ones that have any impact on the anatomic waist. Further rib removal (#8 and #9) will not change the shape of the waistline. In addition while the cartilaginous portions of ribs #8 and #9 can be removed, they require a different incisional approach to remove which is either done by a direct incision over them or through a tummy tuck incision.

I would need to see pictures of your torso and for you to point out the ribs that you see as a problem. But rib removal surgery is limited to the lower end of the ribcage with an emphasis on making the anatomic waistline more defined…which is about at the level of the belly button.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I know I am interested in at least a custom jaw implant. I have noticeable facial asymmetry. What procedures will fix the following concerns? Long face; weak chin, asymmetric jaw;flat face; asymmetric eyelids;and  no browbone projection.

A: Thank you for your inquiry and sending your pictures. In looking at them your biggest facial deficiency is in the lower third of your face. Your entire lower jaw is short, leading to a weaker chin and lack of any jaw angle prominence. Your face would probably not look as long if the lower third of the face was more prominent. There is also some asymmetry of the lower jaw which is magnified because of its underdevelopment. To best treat this type of lower jaw deficiency, a custom jaw implant made from a 3D CT scan would treat both the lower jaw deficiency and asymmetry at the same time.

The flatter face is partly due to the lower jaw but the lack of cheek prominent contributes to it as well. There is where cheek implants would make a contribution.

I don’t see the type of eyelid asymmetry that is easily improvable by eyelid surgery.

Lack of brow bone projection is best treated by a brow bone implant placed through an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions regarding eye reshaping procedures that I don’t think are talked about. I have always liked wide set, narrow, uptilted, “long” eyes that had an excessive horizontal span with minimal vertical height.

I have attached a photo highlighting some things.

1. Can the space between the eyes(interpupillary distance) be increased for cosmetic reasons? 

2. Is there anyway to obliterate an epicanthal fold completely? Not just push it over slightly but actually turn an asian epicanthal fold to a completely caucasian eye with no epicanthal fold.   

3. What surgery would raise the lower eyelid closer towards the medial? When I squint my lower eyelid, it brings up the medial lower eyelid. When I see photos of canthoplasties, it seems they elevate the corners of the eyes to create a severe cat-like look that is in the direction of vertical. 

4. Relating to the top middle photo of my eyes, you can see a before and after of where I am putting a lateral horizontal vector on my eyes. Can this surgically be done with long lasting results? Again, with canthoplasties, they are done all the time as well as brow lifts but these are always either in a vertical pull or 45 degree angle pull. I’m simply looking for a horizontal pull to create an elongated look.

5. In the photos of the two women, they both have narrow, elongated, medial palpebral fissures but more importantly, the outside of their eyes are very long. There is a lot of white show to the lateral part of their irises, is there anyway to extend and create this for someone that does not have a lot of lateral eye exposure? 

6. In the gentleman on the right, he also has a very elongated medial palpebral fissure, even more exagerrated than the two women. can this also be replicated on your average person?

Thank you for your time.

A: In answer to your eye reshaping questions:

1) THE INTERPUPILLARY DISTANCE CAN NOT BE SURGICALLY CHANGED. THAT IS A FUNCTION OF THE MEDIAL ORBITAL WALL BONES AND THE ATTACHMENTS OF THE MEDIAL CANTHAL TENDONS.

2) MEDIAL EPICANTHOPLASTY PARTIALLY OBLITERATES THE FOLD. IF THE L FLAP TECHNIQUE IS DONE TO THE MAXIMUM YOU CAN PROBABLY ELIMINATE IT COMPLETELY BUT AT THE PRICE OF POTENTIALLY ADVERSE AND VISIBLE SCARRING.

3) THERE IS NO SUCH SURGICAL PROCEDURE THAT CAN ACCOMPLISH THAT TYPE OF LOWER EYELID MOVEMENT.

4) THAT IS NOT A CANTHOPLASTY PROCEDURE BUT A CANTHOPEXY PROCEDURE. THAT CAN PULL THE CORNER OF THE OUTER EYE OUTWARD IN A COMPLETELY HORIZONTAL DIRECTION. THE QUESTION IS HOW DOES IT HOLD UP OVER TIME.

5) THE PROBLEM IS IF YOU PULL THE OUTER CORNER OF THE EYE OUTWARD IT WILL LIKELY CREATE A SEPARATION OF THE LATERAL LID MARGIN FROM THE EYEBALL, CREATING A SETUP FOR EXCESSIVE TEARING AND/OR DRY EYES.

6) NO THE MEDIAL PAPLPEBRAL FISSURE CAN NOT BE ELONGATED.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really confused about the types of surgery best suited for me. I do know that my face is too masculine. My cheekbones are too wide, my jaw is angular, and my chin is too long. I have no facial fat or cheeks. I am also wondering about an eye lid and upper and lower lip lift, or some type of lip contouring or mouth reshaping. I like full lips, but my lips seem to protrude and the top lip is really wide when smiling. I don’t know if I need a jaw reduction, chin vertical height reduction, or sliding genioplasty with a reduction in height.I would also like rhinoplasty and possibly a facelift. Overall, my face is just not feminine at all to me and my hair line and forehead looks masculine too. Thanks for your help.

A: Thank you for your inquiry. Based on an assessment of the pictures you sent, let me try and provide you some direction. First of all, let’s start out by eliminating what you don’t need, won’t work or isn’t worth the aesthetic tradeoffs. You would not benefit by a facelift, eyelid lifts or lip lifts. There is nothing you can do about your lip protrusion or how far the upper lip moves when smiling. Your cheek bones are not too wide but they do lack any anterior projection. (fullness) That lack of projection makes you think your cheekbones are wide when they are not. Cheek augmentation here may be beneficial.

Your biggest issue is that your lower jaw is short and angulated downward. This makes the chin horizontally short but vertically long. An intraoral bony sliding genioplasty to vertically shorten your chin and bring it a little forward would be very helpful in getting away from a masculine look.

Your forehead looks masculine to you because it slopes backward. Forehead augmentation to create a more projected and convex forehead shape would make it look more feminine.

In short, your face appears masculine because of its skeletal structure. These are bony issues and changes in the shape of the facial skeleton of the chin, cheeks and forehead would create the appearance of a face that has more anterior projection and less vertical height.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom skull implant. I’m a 52 year-old Asian male and am very interested in your skull augmentation procedure. In my case it would be the higher region of the occipital lobe, about 45 degrees between horizontal and vertical (I’m extremely flat and no volume). Could you please send me as much information as you can regarding the nature of the procedure, costs, risks, scars, recovery, and the maximum possible increase in convexity that can be achieved to that occipital region. Thanks so much.

A: Thank you for your inquiry. Crown of the head augmentation is best done by a custom skull implant made from a 3D CT scan. The critical question is whether the existing scalp laxity will allow for maximum convexity to be achieved as a one-stage procedure or whether it may require a first stage scalp expansion. That would depend on how how much thickness the implant must have to achieve what one sees as maximum convexity. As a general rule, up to 12mms or so can be comfortably done as a one-stage skull implant. Increases of 15mms or greater almost always require a scalp tissue expander first.

I would need to see pictures of your head in profile and do computer imaging to help determine the important consideration of implant thickness required. While custom skull implants can be made to any dimension and thickness, the limitations in their design are in how much the scalp can be stretched to accommodate the underlying added volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in deltoid implants. I was involved in a car accident many years ago which resulted in nerve damage to my left shoulder and caused complete atrophy to my deltoid muscles. I’ve been told that muscle replacement isn’t an option. I was told about the possibility of implants to surround the shoulder to at least give a more natural appearance. I would like more info as to if this is a possibility for me and an estimated cost. 

A: Loss of deltoid muscle mass after nerve damage is very common. Since muscle transplants are not an option for the shoulder area, shoulder augmentation can only be done by either fat injections or deltoid implants. Fat injections are always an option for soft tissue augmentation although how much fat will survive and persist is always their potential downside. Deltoids implants made from a very soft solid silicone material offers assured volume retention but comes with uncommon but potential risk of infection.

The one issue with deltoid implants in cases of shoulder atrophy is how well the existing size of available implants may match the defect. Fortunately silicone body implants are very shapeable during surgery so they usually can be adapted to just about any size soft tissue defect.

The cost of a single one-sided deltoid implant would be in the range of $4,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have developed a small forehead osteoma and I want it removed. I am 38 years old but still wear my hair back, and show all of my face, wear light makeup, and do not want this on my forehead. I could get away with bangs but I really want to keep my face open and clear. I have no idea why I have developed this, I did hit my head as a child in this area, and may have hit it over the years, but it has just shown up in the last year front and center sad to say. I am looking for a ballpark price to have it removed, not an exact I understand, but a ball park quote.

A: I would need to see a picture of your forehead osteoma to determine its location and the best way to do its removal. The other issue to be addressed, particularly if it is sitting over the frontal sinus, is whether it involves the frontal sinus or just sitting on the outer table of the frontal sinus. Its location and frontal sinus involvement can make a very big difference in how it is treated. If you do not have a CT scan of it, then that needs to be done so the proper diagnosis can be done. Until alt his information is obtained the costs of surgery can not be precisely determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like further information on scrotal reduction surgery. I am 57 years old and my testicles are loosening with age. I have never had high and tight testicles but would like to. I have no idea how much testicle size influences the sack or is the sack responsible for keep them up. I saw the scrotoplasty photograph on your site and would be interested in looking like the photo.

A: Like breast mounds in females, the overlying scrotal skin envelope (sac) of the testicles is responsible for their shape and degree of sag. The more scrotal skin that exists, the lower and more loose the scrotum will hang. In the long-term the size of the testicles probably does have some influence on the amount of scrotal skin that develops. But testicular size can not be changed and their influence is a very long-term effect.

A scrotal reduction or scrotal lift (scrotoplasty) involves the removal of a central strip of scrotal skin done through the natural raphe that exists between the two scrotal halfs. Many scrotums actually have a midline raphe that creates a bit of a vertical cleft through the bottom of the scrotum, making a perfect place to place a fine line scar. This is an operation that is performed as an outpatient under anesthesia. Dissolveable sutures are used with an overlying glue as a topical dressing. One may resume showering the very next day and normal underwear may be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant revision. I had 375cc filled to 425cc saline over the muscle implants placed 20 years ago. I got them after the birth of my first child. I went on to have 4 more children and breastfed all of them. I am 5’4″ and 130 pounds. I feel best at 110 pounds but the rippling of the saline implants is terrible and embarrassing at that weight. I would really like to lose weight, deal with the rippling and switch to silicone implants. Was hoping to increase size to 525-625 if possible. I am worried about animation deformity with under the muscle. I do not like that possibility at all. Can it be avoided? The doctor’s here are very conservative size wise and the ones I have consulted with do not like or offer silicone. They did say switching from over to under would be an very easy procedure but I would like to avoid saline implants. One Dr  from several states away recommended fully under muscle implants. Didn’t even know that was possible. Another recommend acellular matrix grafts with silicone under muscle to minimize but not eliminate any visible movement. Have heard great things about your work and would really appreciate you opinion and ideas on what can be done.

A: Thank you for your inquiry. Let me help clarify all of the breast implant revision options you have presented as they cover every single onethat is available. First of all, the shape of your breast mounds and position of your nipple-areolar complexes are extraordinarily good for someone who had had four children and breastfed them after the original breast augmentation procedure. It is very rare to find someone with your history that does not need a major breast lift at this point. So the approach of simply changing breast implants is a viable one for you.

There is no question that you want to switch to silicone implants. I am shocked to hear that in your area they don’t use silicone breast implants. In contemporary breast implant surgery saline implants today make up less than 25% of implants used and are only used because of their lower costs. They are are inferior implant in regards to feel and longevity compared to silicone implants. While silicone implants will not completely eliminate all rippling, they will go a long way to eliminating the majority of these palpable and visible implant folds.

The next issue is that of either keeping your existing implant location or switching to an under the muscle location. You have essentially decided that already in that any under muscle location will cause an animation deformity. That is an unavoidable issue since most submuscular positions are really partially under the muscle and the side of the implant is only right under the skin. Thus when the pectoralis muscle moves the implant is ‘unchecked’ at the side and it moves in that direction. Maneuvers such as placing ADM grafts to totally cover the implant edge or moving muscle from the side of the chest wall up over the implant can be done to reduce/eliminate that problem. However, increasing the implant size to 600cc makes making a complete submuscular pocket impossible. (implants are too big to get full muscular coverage) The use of ADM grafts is an option for coverage but that will add over $6500 to the cost of surgery for implant cost and time of placement, exponentially increasing the cost of breast implant revision surgery.

I see no problem with switching your existing implant size to 600cc plus, but as you can see you can not have everything that you want. (no animation deformity, no visible rippling, reasonable costs) Thus what I see as the most acceptable option for you to go with a high profile, round smooth silicone implant that remains in your current subglandular position. I prefer the submuscular position almost always and the animation deformity may not be that significant but that may not be risk that is appealing to you

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have frontal bossing on the upper forehead below the hairline on either side. Many specialists say this can be easily treated with fat grafting but what about the long term side affects? I would greatly appreciate any details.

A: The treatment of frontal bossing can take two very different directions. One is a reductive approach to frontal bossing which involves burring down the prominent forehead bony protrusions through a hairline or more posterior scalp incision. The opposite approach is an augmentative one where the areas around the frontal bossing is built up. This is usually best done by adding bone cement material to the ‘deficient’ areas around the frontal bossing also done through an incision similar to the reductive approach.

Whether one should have an an augmentative or reductive approach to their frontal bossing is one of aesthetics. Which type of change of forehead change will look the best? That would depend on the each individual patient and their degree of frontal bossing and forehead shape. I would need to see some pictures of your forehead to better answer that very important treatment decision.

The use of fat grafting in the treatment of frontal bossing falls into the augmentative approach. It differs from bone cements in multiple ways including the elimination of an incision (good thing) but with unpredictable fat survival and rarely creates a very smooth forehead contour. (bad things) But if augmentation is the best aesthetic treatment, these risks may be worth it including the potential need for a second fat grafting session. However if a reductive approach is the best aesthetic choice, fat grafting would be a poor treatment choice no matter how well it was performed or how much fat survives. One wants to avoid making the overall forehead too big.

Dr. Barry Eppley
Indianapolis, Indiana