Your Questions

Q: Dr. Eppley, I had a revision of my primary rhinoplasty last summer and don’t like the shape of the nostrils and the tip. I also don’t breathe well from right nostril. Do you think I need grafts from ears or rib??

A: In looking at your frontal picture, I see widely spaced domes on the tip and significant tip asymmetry due to the right alar rim being very low compared to the left side. The profile view from the left side show a big step-off at the mid-columellar incision.

Your nose certainly has room for improvement, particularly given that you have had two rhinoplasty procedures. Why you have ended up with this result is a bit puzzling given that you have had open rhinoplasty approaches. I certainly would be tempted to say that further improvement is certainly possible but whether cartilage grafts are required to do it is a bit premature. It would be helpful to have more information if possible such as the operative notes from the two operations. That issue aside, what is needed always becomes evident in a revision when the tip is degloved and anatomy of the tip cartilages become evident. While swelling and scar tissue can obscure underlying tip cartilage anatomy, most external tip deformities are a direct result of how the underlying cartilages are shaped. You have such a significant tip deformity that I would wager the right lower alar cartilage is twisted and rotated downward, perhaps due to lack of support. In that case, cartilage grafts are needed such as a strong columellar strut from the septum and an alar onlay graft from ear cartilage. I would doubt that rib cartilage is needed. But I would leave that as an option to be determined during your revisional rhinoplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question about the skull contouring procedures that you do. My question is that can a small strip of bone be burred down from the top of my head which is pointed and thick, back down do the forehead? I’ve seen a video on Youtube where they do this for metopic synostosis.

A: What you are referring to is the reduction of a midline or sagittal ridge of bone, which represents the original fusion of the sagittal suture between the front (forehead) and back (occipital) fontanelles. In some people this line of sutural fusion can get quite thick and becomes a raised ridge of bone that can be quote prominent. This midline ridge of bone can be burred down (reduction cranioplasty) so that it is more level with the surrounding bone. How much it can be reduced depends on how thick the skull is along the ridge.Usually the ridge is thicker than the surrounding bone so that is not a problem. But it is a good idea to check its thickness first with an x-ray before actually having the procedure.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 30 year old male with a odd shape head that hunts me still now. I keep a lot of hair on my head to give my head a fuller look. I also constantly cover my head with a bandanna, sleep with it on my head, never remove it. My head sweats, get dried and builds up a bad case of dander because I hate my head shape and smallness…. I need help with this problem and people is driving me crazy, I haven’t been outside normally for 13 years, only go out when I have no choice. It is all my mother fault, she shaped my head by pressing on it when I was a child because she believed wide flat foreheads are a great look for men but she done it all wrong, I am flat front and back, my skull is small as well…. please help me! 

A: Your description of your unhappy head shape sounds like fronto-occipital flatness. This could be improved by augmentation of your forehead and the back of your head by an onlay cranioplasty. Whether both areas should be done or just the front or the back would depend on the area of the greatest aesthetic concern. How much augmentation can be done depends on what your scalp will permit by stretching. By using a coronal scalp incision between the two areas, good scalp expansion can be obtained and the closure of the incision is well away from the material location which is always a bonus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m emailing to consult on your ability to improve some concerns that has not been ameliorated through exercise and diet.  I am 5’10 and weight 172 pounds.  Specifically, my upper cheeks and face carry a significant amount of fat which appears to be genetic and gives my face a chubby look.  I have attached pictures and circled the areas of my concern. In addition, I’m curious what you can do for the fat in my chest and underarm area.  A number of military guys I have spoken with have mentioned a procedure known as “pectoral etching”.  What it sounds like is liposuction in this area with some contouring to create a more defined/chiseled pectoral look.

A: What you are demonstrating in your pictures is a zone of cheek and perioral subcutaneous fat, a layer that lies just under the skin. It should not be confused with deeper fat layers, such as the buccal fat pad, which it is not. These are very difficult areas to successfully reduce although its treatment is straightforward. Small cannula liposuction is used from a small incision inside the mouth and the bottom end of the nasolabial fold. In my experience I have seen good and mediocre results with this procedure. The hardest area to improve is that closest to the eye. The other  issue with facial liposuction in this area is some prolonged swelling. While this is very typical of liposuction anywhere, it is very visibly noticeable when it is in the middle of your face.

From a chest standpoint, you are correct about pectoral etching. There is nothing magical about this technique. It is the artistic use of liposuction to create a better pectoral definition, largely using reduction of the lateral pectoral triangle for its effect. I have used it frequently with overall chest liposuction in male gynecomastia liposuction surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know it will cost more money if you are a plus size women to receive Buttock Augmentation by Fat Transfer but is it still safe or do you recomended the person lose weight first. I would love to get the procedure but want to do what works the best. I want my butt area to be considerably larger and I thought being bigger would be better for what I’m trying to achieve because I have more fat to transfer but its only been a bigger headache considering most of my weight comes from my breast area. 

A: Your understanding of how much fat that can be transferred to the buttocks is correct. The more you have to give, the more that can be transferred. It is never a good idea to lose weight before having a BBL (Brazilian Butt Lift) because you are going to lose it from the donor sites,, (abdomen and flanks) The fat that is liposuctioned out for transfer has to be filtered, washed and concentrated before being injected into the buttocks. This means that only about 1/3 of what is suctioned out will be usable. This makes it clear why few patients ever have too much fat to use. I would have to see a picture of your stomach area/body to see how much you have to give you a specific answer as it applies to you, but these are some basic guidelines about fat transfer to the buttocks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year old women who is a little overweight. At 5’4” and 190 lbs, I wouldn’t call myself fat just above my ideal body weight. The reality is that this weight is very stable and have been relatively the same weight for almost 20 years. I exercise and eat reasonably and this is just the way it is. I am fine with that as I am otherwise healthy.  My face has always been al little plump but otherwise firm until the past few years. I have noticed that there is some jowling that has appeared along the jawline but the real problem is my neck. It has gone to hell in the proverbial hand basket. It has gotten so droopy and saggy that I know it is time for some type of necklift. My question is am I too fat to get any benefit from such a procedure?

A: Your question is a good one and would be a lot more relevant when you were younger. But as you have gotten older, enough though it sounds like you have a rounder fuller face, the skin in the neck has begun sag. This sagging is the result of the skin stretching and loosening, no longer being able to support the weight of the fat it contains. While I would have to see pictures of your neck to be certain, many females with similar situations and face shapes actually get great benefit from neck reduction/tightening. Until proven otherwise, it may be that you may get a greater benefit from a necklift than someone who is thinner with less loose skin. It would make sense to delay your facelift if you were planning on losing weight but that clearly is not the case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having an otoplasty (ear pinning) soon and want to do everything to help it heal well. I take a cartilage supplement glucosamine-chondroitin liquid, Joint Juice) daily because of a previous knee injury. The supplement also contains green tea extract as well as multiple vitamins and a few carbs. Is it ok to keep taking it for my surgery? It is supposed to help strengthen cartilage so do you think it would be helpful for recovery? Should I double up on my amount per day to make my ears heal better?

A: In the nutritional supplement craze in which we live, it is very logical to ask if a cartilage repair supplement might help an otoplasty to heal better. After all, an otoplasty works by cartilage bending and healing in a new position. To make the linear assumption then that a supplement to repair cartilage should be helpful for healing ear cartilage as well would seem to make sense. The only thing I can say for sure is that your continued use  of it will have no adverse effects on your otoplasty healing. Whether it has any benefit at all is unknown and doubtful. There is a big difference in the cartilage of a synovial-lined joint and that in the ear or nose. That is an assumption that probably wouldn’t hold up under any scientific scrutiny. Therefore, I would not increase your intake of this supplement for your otoplasty surgery. The only real beneficiary of that approach would likely be the manufacturer of the product.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I need jaw implants from the gonial to the chin area. I have had a sliding genioplasty at the chin several years ago.  I have a short jaw bone that angles upward from the chin area to the bottom of the ear. I need to bring this to a more horizontal angle.

A: Thank you for your inquiry. It sounds like you have a pretty good handle on what you need. Ideally you need custom jaw angle implants that extend from the jaw angle right up to the chin area. Such an implant is not available as a stock or off-the-shelf implants. Off-the-shelf jaw angle implants will not reach the chin area, at best they will reach to the mid-body of the mandible behind the cut or notch from the prior osteotomy. That is an acceptable approach if one can accept an indentation between the chin and the jaw angles. But a completely smooth transition from the chin back to the jaw angles requires a custom implant approach based on a 3-D model mandibular model made from a CT scan. This is the best and only way to get a jawline that is completely harmonious fro one side to the other.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old woman and am bothered by the amount of skin under my chin. I would like a more youthful and tightened neck look. I have read about lot of different neck rejuvenating procedures such as a necklift and a ‘trampoline’ neck lift. the necklift/facelift seems like it is too much for my problem while the reviews I have read on the trampoline lift do not give me much confidence. What would be the best procedure for my sagging neck skin?

A: There are a variety of neck tightening procedures as you have mentioned. In the array of neck improvement options, they have differing effects on neck rejuvenation depending upon what they are designed to treat. Given your relatively young age, it is hard to imagine that you have enough loose skin to warrant the maximal tightening procedure of a full necklift. It may be that simple liposuction, particularly Smartlipo or laser liposuction, may create enough of a skin tightening effect. This  would depend on whether you also have enough fat in the neck to warrant it. A so-called trampoline necklift achieves its skin tightening effect from liposuction. The sutures placed are designed to create a sharper cervicomental neck angle not to tighten the skin. A more simplified version of this procedure is the standard submentoplasty where sutures are placed to tighten the platysma muscle above the thyroid cartilage and liposuction is used to reduce fat and tighten skin. I would really have to see pictures of your neck to determine what may be of best benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am coming for a facelift and chin augmentation from out of the country and have a visa to travel to the U.S. But my wife does not so she can not accompany me there. How do you handle the arrangements for after surgery care in patients in my situation?

A: Almost every male patient that comes from afar to my practice comes alone. This is actually common and we are very familiar with handling such a situation. Postoperative care would be provided by either staying overnite in the facility or we arrange to have one of our nurses take you back and stay with you the first night after surgery in our hotel. Being from out of town and having a facelift (and being a male), staying overnite in the facility would be the more ideal postoperative scenario. Once the drains and hear dressing are removed the next morning, you will be in a better situation to be by yourself the next day after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get a facelift and chin implant at the same time. In remaking a new jawline (or a rejuvenated one), I thought that maybe jaw angle implants would be beneficial as well. Do you think it would give my jawline more definition?

A: My concern about jaw angle augmentation in your face is that the only effect it may have would be to make it look bigger/rounder/more fat. Your tissues are so thick over the parotid gland/jaw angle area that it would provide no definition and just bulk. And the last thing you need is more bulk/width in the posterior part of your face. Jaw angle implants work best in a thinner or already more defined face where the outline of the implants can be better seen. Jaw angle implants are not just about adding bulk. That result is often not helpful, and even detrimental, to the aesthetics of a fuller face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get a new chin augmentation procedure. I had one done over 20 years ago but I always thought it wasn’t enough. It was done from an incision inside my mouth. In getting a new and larger implant, would the old chin implant have to be removed?

A: Whether your existing chin implant would be removed or not during the placement of a new one is an intraoperative decision. In theory, one would assume that the old one would have to go to make way for the new one. But this is not always true. Given that your original chin implant was placed over 20 years ago and was placed from an intraoral approach, it is likely that it is very small and positioned high on the bone. If it is not in the way, I will often leave the old one and placed a new one right on top or below it taking advantage of whatever augmentative effect it already provides. If it is positioned low I may either remove it, or if it has settled into the bone, I may just shave off the prominent part of the old chin implant to make a smooth platform for the new one to rest on.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be very grateful if you could answer some questions about the removal of the buccal fat pad. What is the level of risks of sustaining damage to the buccal nerve branch of the facial nerve? Approximately how long does it take to recovery and when to expect the end result?

A: The buccal fat pad is an encapsulated fat mass in the cheek which is located between the buccinator muscle and the masseter and zygomatic muscles and largely lies underneath the zygomatic arch.  It is deep to the malar fat pad which lies directly under the skin and the jowl fat pad which is situated much lower near the jawline and should not be confused with these two regionally close fat collections. The buccal fat has one large body and usually four processes like fingers which extend outward from it. The part that is removed in a cosmetic buccal lipectomy is part of the main body. The biggest risk in buccal lipectomy is transection of its blood supply,  the buccal artery or vein during its removal. This can result in bleeding and a hematoma afterwards. The key to avoiding this complication is gentle dissection of the main body outward and cauterizing attached blood vessels under direct vision. The buccal branches of the facial nerve are in close proximity to the main body but usually cross over top of it. Staying inside the buccal fat pad capsule and not being too aggressive with removal are the keys to avoiding a traction nerve injury. It is not a complication that I have ever seen. Trying to pull too much fat out runs the risks of pulling the nerve branches into the field of removal/cautery.

Buccal lipectomies will cause some swelling but most of that is gone after about three weeks from the procedure. The final result can be judged six weeks from surgery although some continuing fat atrophy may be ongoing based on how the fat pad was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year-old woman who would like a facelift to remove jowls and improve droopy neck. I also would like my nose done as the tip seems to keep getting lower as I age. (is it really growing at my age?) The question I have is the timing of the nose surgery and the facelift. Should they be done separately or together? If separate, should the nose be done before or after the facelift? My thought would be after because it give my surgeon a better idea to do the nose based on the new way my face looks.

A: You are correct in your impression that the nose is getting longer and ‘growing’. It does not actually grow per se but the tip of the nose does fall as the ligaments weaken. As the tip falls downward the nasal length increases and the nasolabial angle decreases. This means that a very simple tip rhinoplasty to elevate the tip and open up the nasolabial angle can be quite rejuvenating to how the face looks.

There are arguments to be made on both sides of that discussion either combining or separating a facelift and rhinoplasty. In reality, it is not necessary to look at the ‘new’ face afterward to figure out how to change the nose via rhinoplasty surgery. Therefore, I have found it best to combine the procedures for the benefits of one single surgery and recovery and lower costs. In addition, a rhinoplasty is a central facial surgery while a facelift is a lateral or side facial surgery. One does not really impact the other when it comes to facial appearance changes or swelling and bruising. Put together, however, the combined facelift and rhinoplasty procedure can have quite a rejuvenating impact on the aging face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to improve my profile. I am 53 years old and have always had a round face. But as I have gotten older and gained weight, it has gotten more so. About 20 years ago I had a chin implant placed. It helped a little but the result was not what I was looking for but I have lived with it. Now I would like to rejuvenate myself a little bit and get my jawline looking better. I have attached front and side pictures for your recommendations.

A: Thank you for your inquiry and sending your photos. In looking at them, you have chosen the correct procedures, neck recontouring and chin augmentation. The chin augmentation is straight forward. A forward projecting chin implant of 8mm to 9mms would give much improved augmentation.  This is in addition to the chin implant you already have. I suspect it is a very small inplant that is likely placed too high on the bone. So I would remove it and replace it with one that is bigger, more square-shaped and positioned lower on the bone. Your very full neck (bullfrog neck deformity) is the challenging procedure. This can be approached from three different approaches; liposuction only, liposuction with submentoplasty or a full necklift. I think with your size neck and excess skin that only a full necklift will give you the maximal improvement. Males with thick necks never get as much tightening and cervicomental angle creation as females so the most aggressive approach needs to be done. I have attached a side imaging profile to show what I consider to be a conservative result, meaning the least amount of improvement that I would expect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Could you explain briefly your procedure for eyebrow hair transplantation. Most are done through follicular units containing single hairs at a shaved donation site located in the back of the scalp. I know you can use the fine hairs behind the ear as the donor site. The question is do you shave that area site also?  Or do you transplant the recipient areas with the original length of that donor hair? My eyebrows are very light in density due to chemotherapy (in 2005) and possibly the present medication Fluconazole I am on which I will be taking for a few more months. My eyebrows  will never be the same. If I could just get an idea of about how much it might cost,for about anywhere from 60 to  100 hairs per eyebrow, I’ve been approved by care credit. But I don’t want to waste your time if I don’t have nearly enough to cover the cost. Thanks so much.

A: Eyebrow hair transplantation is unique only because of how the hairs need to be oriented in the brow area. The harvest and placement of the hairs is a standard single follicular unit technique. Where on the scalp the hairs are harvested is a function of how thick they need to be. Whether they are harvested from the back of the scalp or behind the ears is merely a function of the color and thickness of the hair shafts needed. The lighter and thinner the hairs needed, the more likely they would come from behind the ears over the mastoid area. No hairs are shaved for harvest because the shaft must be present to act as a handle for manipulation and insertion. The shaft may be cit very short but not shaved.
The antifungal drug Fluconazole has a well known side effect of hair loss, thus it would be best to not have the procedure before you have discontinued this medication.
The cost of hair transplantation can be done on a per follicle basis or by hair region. Eye brow transplantation is usually charged for by region. 

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a transitioning female-to-male transgender individual and my goal is to create a more masculine appearance. In particular, I have a very round, feminine face. I believe chin implants and possible jaw implants/contouring would help a lot, but I am open to hear suggestions as well.  I’m very concerned about price given my student status.

A: When it comes to making a face more masculine, you are correct to first look at the jawline. That is one of the top areas in facial contouring in FTM transgender patients. your photos show a really soft jawline and that it makes priority number one from a surgical altering aspect. The rest of your face, as you have pointed out is round and feminine. From a both a cost and an effectiveness standpoint, I would focus on chin augmentation and buccal and submental fat reduction. In other words, a combined chin implant, submental liposuction and partial buccal lipectomies. This will help your jawline considerably and create improved definition sa shown in the computer imaging that I have done. The only debate about the chin procedure is whether it should be an implant or an osteotomy. Ideally, it should be an osteotomy because of your age  and the need for some vertical chin lengthening as well. But there is a cost difference between a chin implant and an osteotomy and that has to be factored into your treatment decision as well as you mentioned. Jaw angle implants are also an option but are far less important than chin augmentation in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions about building out a flat spot on my skull. I have attached some pictures for your evaluation. My questions are:

1)  Since the Kryptonite material is no more available there is only the PMMA,Hydroxyalite(HA) and custom silicone implant available. If I understand well all these materials are requiring an open approach under general anesthesia for two hours

and they all leave a scar between 8-10cm when they are introduced under the scalp. Will the scar be visible if i keep my hair a little longer then short?

2) Other than a scar ,minor contour issues remain as the only risk. If these contour issues ever occur later after surgery, what have to be done and how?

3) Hydroxyapatite material bonds to the bone with no risk of osteolysis. Does it make then (HA) safer than PMMA in that matter?

4)What is the biggest disadvantage in using hydroxyapatite material?

5) The safety is my biggest concern long after the surgery, which of these materials are best proven over the years? 

6) I would be traveling from abroad. How long do I have to stay in the U.S. and do I need some special medical insurance in case something goes wrong during the surgery.

A: Based on your photos, what I see you are demonstrating is a severe flatness to the back of the head, lack of occipital projection. In answer to your questions:

1) The  posterior scalp scar is about 8 to 10 cms that with hair will remain hidden. There are numerous bald.shaved patients who have the procedure as well but I think it is a good idea to be well aware of the scar potential.

2) If any contour issue arises, such as an edge than one can feel or some asymmetry, it can be easily adjusted/fixed through the same scar approach. I go to great lengths to avoid that happening for the obvious reason…no patient wants to go back to surgery. But despite my best efforts, surgery is not always perfect.

3) HA does have a direct bone to bone so, in theory, it is a more biocompatible material. I wouldn’t use the word safer as both materials have been used successfully for decades. But if I was a young person and had a choice between the two materials (cost is the big issue) then I would go with HA>

4) Cost is the only disadvantage to the HA material. By volume alone, it takes twice as much HSA to get the same volume effect as PMMA>

5) PMMA has been used as a cranioplasty material for over 40 years. HA has been used for over 25 years.

6) Almost all cranioplasty patients return home within 48 hours after surgery. No special medical insurance is needed as nothing is going to go wrong that would warrant any catastrophic medical care. This is the simple addition of a material on the outside of the skull bones, it is very safe. The risks of this surgery are aesthetic concerns not significant medical complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Hi. I read article you wrote online.  I had a “lifestyle lift” six weeks ago.  I had a mild turkey neck. After surgery I had a significant swelling in my mid neck bilaterally.  Now much of the swelling is reduced but my previously unseen thyroid cartilage is now revealed. (I am a woman.) In your experience does this ever go away or will I need revision?  Thanks so much for any help you can offer.

A:  Unmasking of the thyroid cartilage would suggest that you had a very good midline pull and recontouring from the Lifestyle Lift procedure. I don’t know whether you had platysmal muscle plication or not (you would know if there is an incision under the chin), but the lateral pull of the skin and the defatting of a platysmal separation and its reapproximation can create a very improved cervicomental angle. These standard facelift maneuvers can occasionally make the outlines of the thyroid cartilage evident, particularly in the thin patient with little subcutaneous fat.

There is no way to undo the lift to camouflage the thyroid cartilage again. Continued aging will eventually cover up the thyroid cartilage again bit that is obviously going to take time and there is no guarantee that it will do so. An alternative suggestion is to do a simple thyroid cartilage reduction (tracheal shave). This is a common procedure to reduce the jutting and prominent thyroid cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know of you can take fatty tissue from another part of your body and inject it into your butt to make it rounder where it has dropped due to loss of elasticity. I am a 50 year old lady and I am a diabetic.

A:  Transferring fat, usually from the abdomen and flanks, into the buttocks is a very common procedure today. Known by the name of a Brazilian Butt Lift, fat is obtained by liposuction, concentrated and then injected into the gluteal muscle and subcutaneous tissues for an augmentative effect. While the inadvertent body contouring benefit from the procedure is assured (fat reduction), how well the fat that is transferred into the buttocks is not. Survival rates vary widely from 10% to 90% with most patients having an approximate 50% survival rate. What factors affect survival of the injected fat is not precisely known. But having diabetes may be a factor that adversely affects survival, particularly if you have insulin-dependent diabetes. Diabetes that is treated by oral medication is less likely to have a significant impact on fat graft survival.

Another treatment consideration besides fat injection is a lower buttock lift. When the buttock falls over the lower skin crease where it meets with the upper thigh, it may be better treated by excision and re-establishment of a well-defined skin fold. This can also be combined with fat injection for volume increase for an enhanced effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty several years ago after my chin implant had to be removed due to migration. I developed a deep line under my lip and the really tight feeling in my bottom teeth has never subsided. Can anything be done? I have learned to live with it but I am miserable. Thank you.

A:  I suspect that you have a really tight and short vestibule after your genioplasty procedure. This will not only create a deeper labiomental sulcus but can make the lip feel like it is attached right to the gum tissue of the teeth. If I am correct, and there is no way for me to know that for sure based on this conversation, it can be improved. The vestibule needs to be released and the created tissue defect grafted with buccal mucosa. The best way for me to tell if this is the case is to see a picture of your lower lip pulled down so I can see your gums and the scarred vestibule.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been very pleased with the surgery you performed on me this past May. By the end of 2011, I started have chronic migraines (pulsing in temples). It was really debilitating and interfered with my work, going out with my friends and husband, and everyday activities like working out. After the surgery, I am no longer in constant pain and I feel like I am getting my life back! I still have some minor pulsing in my temples. I am working with a local Neurologist to try to alleviate the pulsing. But even if we never resolve the pulsing, I feel like I will be able to live a normal life. Since the surgery, I have started having some pain in my forehead (right between my eyebrows and right above the eyebrows). It not nearly as extreme or painful as what I had experienced in the temples. It does not occur every day. The Neurologist has prescribed a low dose of Baclofen to take when I feel the forehead tension and that works well. But I was curious whether it would not just be better treated surgically? I had read that patients sometimes develop secondary trigger spots after having the primary trigger spot operated on. I was wondering if you thought that it might worth having a second operation done. What exactly would the procedure be, are the muscles removed?

A:  It is well known that the successful treatment of one trigger point for migraines can potentially unmask or uncover another more minor but contributing source. For the temporal-based migraines, the unmasked trigger point is the suprarobital-supratrochlear region located in the  inner brow area. Unlike the temporal region, this migraine trigger site is treated differently. It is approached using an endoscopic technique from two small incisions behind the frontal hairline. Through the endoscope, the muscles are removed from around the nerves as much as possible and, in some cases, the bony foramen where the nerves emerge from the brow bone are opened up to decompress the nerve completely. This takes the same amount of time to complete, around one hour, as the temporal migraine surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a SMAS facelift two weeks ago. I have swelling and numbness alongside stitches and jawline. Although the swelling is even on both sides the swelling feels dense, thick and kind of hardish. Is this normal? Also, I have these slight dents under my cheek bones that I believe is caused by where majority of swelling begins. Is this normal? I have good things to report about my recovery, bruising is gone, symmetry is good,  no pain and it looks like I am going to get the result I am after.

A:  Recovery from a facelift procedure is rarely as fast as any patient would like. The skin will be numb for weeks to months where the skin flaps were raised and along the suture lines. The swelling will go away much quicker but it is perfectly normal for the face to feel firm and still a bit swollen at just two weeks after surgery. Expect all swelling to be gone by six weeks after surgery. Some of the facial features that are outside the zone of the facelift, such as the cheeks, may appear different because of the swelling around it. Your facelift recovery sounds perfectly normal and you appear to even be a bit ahead of schedule for what many patients experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a frontal sinus obliteration with a bicoronal approach.  Titanum plates and screws were used to secure a bone flap.  Soon after all the hardware was show thru and I went through a second surgery to have it all removed.  Now i found out the bone flap which was pretty large is resorped, which is no surprise as my forehead has a significant deep “thumbprint” and also other various irregularities.  I am getting mixed opinions.  Cement, no cement “It can be a nightmare”  Iliac bone crest graft. Titanium mesh etc.  Also my soft tissue is thinned out because a portion of the forehead tissue was used in the obliteration.  Can you help me ?

A: It sounds like you had an osteoplastic frontal sinus procedure using a pericranial flap top cover the obliteration. I will assume that much of the frontal bone flap has resorbed, resulting in indentations and irregularities. I have seen this before and I don’t think it will be a ‘nightmare’. It will be scarred for sure and there may be some exposure into the residual frontal sinus areas. It rebuilding the brows and lower forehead, I would definitely use hydroxyapatite bone cement. (not acrylic/PMMA) bone cement. I would not use titanium mesh (as this will cause the same problems you had with previous hardware) or bone grafts. (they will largely resorb also) The thinning out of the overlying scalp and potential exposure to the frontal sinus makes it imperative that the most stable but biocompatible material be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in either smartlipo or lipo dissolve for my abdomen/love handles. I was wondering if you do Smart lipo under local anesthetic or if you require going under general (I really do not want to go under general anesthetic). Also, I was wondering if you knew approx costs for those procedures.

A: Any form of liposuction, like most surgeries, can be done under local anesthesia. The potential use of local anesthesia is a common inquiry in regards to liposuction. The question is not whether liposuction can be done under local anesthesia but whether it should. Contrary to popular perception and much marketing, the results from doing liposuction under local anesthesia versus general are not the same. Often the results are not even remotely comparable in my experience. The results from any liposuction endeavor is entirely dependent on effort and being thorough. While local anesthesia provides some pain reduction, it is rarely enough to do a good job of maximal fat extraction. The patient’s level of discomfort always becomes a limiting factor. The size of the operative field that must be made numb in liposuction is quite different than that of just a small surgical incision.

I honor patient’s requests to do liposuction under local anesthesia but I caution them that one must be prepared to accept much less of a result. This is particularly true in large areas like the abdomen and flanks. (i.e., love handles) Interestingly, and quite surprisingly, the cost of liposuction under local anesthesia will ultimately cost more than if done under general anesthesia. The simple explanation is that it often takes two or three times the amount of time for me to do liposuction under local anesthesia than what can be accomplished much faster (and better)  under general anesthesia.

In addition, lipodissolve injections are no longer done for significant fat removal and are certainly not a replacement or alternative to any form of liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really appreciate you for trying to help me out at this miserable situation. I had chin implant removal surgery 16 days ago. Dr. took out my Medpore implant from inside my mouth. Fortunately the look of my chin has not changed dramatically but the problem is when I talk you can see my lower gum which is a disaster to me and hurting my confidence badly. I saw my surgeon one week after the surgery and he said I should wait for six weeks, but now after more than two weeks the problem looks getting worse. My question is if this problem gonna improve? if not is there any fixation in the future for this problem or not?

A: What you are experiencing is a soft tissue chin ptosis problem. When implants are removed from an intraoral approach, it is important to resuspend the mentalis muscles and soft tissues of the chin. Remember that they have been stretched out from the implant and then cut through for the removal of the implant. If not tightened and resuspended to the bone, they will both fall and contract downward, exposing increased tooth and gum and even creating lower lip incompetence. I doubt that the tissues will magically move upward as they heal. But I would wait three months after surgery and make a decision then. I suspect you will need a soft tissue/mentalis muscle suspension for correction of this problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to request for your thoughts in chin ptosis correction, which I found out through Q&A’s on your website.  I had a fairly large chin implant removed due to infection 2 years ago, which left me with my current chin ptosis condition. The implant was in my body for 10 months, so the capsule is still left in me for horizontal projection.  I am happy with the projection it gives, except that the capsule sits high part of my chin (just below my lower lip), and there is a difference between where my lower part of my chin bone starts and where the capsule lies. Since the primary concern is loose skin, I would love to have some form of skin-tightening or skin-cutting without showing the gap between my capsule and my chin bone. (in picture I am grabbing the loose tissue)  I consulted about this issue with a previous surgeon who placed an chin implantl and he just didn’t know what to do. He told me he has never seen this level of chin ptosis, and he just ended up recommending another sliding genioplasty and chin implant. I am personally satisfied with my current forward projection through capsule, and I am not sure if I will need more chin augmentation.

A: By definition what you demonstrating by grabbing is a procedure known as submentoplasty. To me your ptosis is really submental in location and not on the chin point at all. A submentoplasty procedure involves a curved submental incision under the chin to remove skin and fat and tighten the neck. I don’t think that will get rid of all your submental ptosis because to do so would involve a longer incision that I would not feel comfortable doing in a male with your skin pigment and ethnicity. The best result comes from a direct necklift but a vertical incision should never be done on your neck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am would be interested in some procedures that could help me improve upon my face, in terms of structure, proportion, balance and profile. Please see my attached photos and let me know what can be achieved in terms of improving my facial structure. To highlight some areas I would be seeking improvement, I would like a more defined, less saggy neckline and a more contoured, defined, less square like face with a  narrower facial shape, upper half of the face broader in relation to the lower face. By playing with some photo editing software I got some results that looked interesting (see before and after picture). I am curious what is achievable in reality. What procedures would you recommend to achieve the results I need?

A: Thank you for your inquiry and sending your pictures. Essentially what you would like to achieve is to make some changes so that your face has more definition and less of a round and indistinct shape and contours. From that perspective, there are a variety of procedures that can be done to help achieve that overall goal. Given that it is a more total facial metamorphosis, there is no one single procedure that will achieve it. Rather it is a combination of smaller skeletal and soft tissue procedures that need to be done.

I would recommend some soft tissue contouring by neck, jaw angle and perioral liposuction combined with partial buccal lipectomies. In conjunction i would do some small cheek implants and a small more central chin implant to provide some better skeletal highlights. (narrower chin and more V-shaped face from front view) As you can see, this approach uses a combination of soft tissue reduction and skeletal augmentation to obtain a face that has more overall definition.

I have attached some imaging to demonstrate that potential outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I met with a facial trauma seven months before and doctor have to put plates on my right zygoma bone and maxillary sinus and eye socket with 14 screws. But now I feel a lot of pain under my eye and cheek. So can removal of plates help me from getting an infection? What can be the right time to remove them? What can be complications in future? Will my bones have an adverse effect of it or they will remain healthy?

A: As a general rule, fixation hardware (plates and screws) are not removed after facial fracture repair unless there is a distinct problem. Such problems could be pain from device loosening or palpability or cold temperature transmission (usually around the eye area) Most facial plates and screws today are made of titanium which is very biocompatible and does not have any long-term issues such as corrosion or degradation. Because of the trauma of additional surgery, one therefore should have a compelling reason for removal. Should removal be necessary, they can safely be removed six months after the original repair surgery. Facial bones heal quickly and are very stable at that time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My cheekbone injury is over 8 years old. I know doctors are leary of healed/mended cheekbones. Should have initially went to hospital but because of lack of insurance and being raised to believe a black eye is just that. I was even getting carded at 30, took only about 8months before that ended. So now I am 38 and skin is creased/hollowed only on that side. I went to a plastic surgeon but they don’t know what I am talking about. 

A: Many untreated depressed zygomatic (cheekbone) fractures will eventually show a malar or cheek flattening once all the swelling has subsided and the tissues are retracted. For many only the cheek is flatter but in more severe cases the shape of the eye may have changed and the corner of the eye tilted slightly downward. Yours sound like it has malar involvement only. A small cheek implant can usually make a significant improvement. Placed through the mouth on just one side, this can provide a simple and immediate fix to your cheek flatness/hollowness.

Dr. Barry Eppley

Indianapolis, Indiana