Your Questions

Q: Dr. Eppley, I want custom jawline implants placed.  I want to know how difficult the operation is to place custom Medpor jaw angle implants? I have had two surgeries, a bilateral sagittal split ramus osteotomy with genioplasty and an inverted ramus osteotomy to correct the sagittal split osteotomy. Even though I have custom Medpor jaw angle implants already fabricated, I am not comfortable with my current surgeon to place them…I want to know if you would be able to take over the case? What is the risk of infection? Thanks in advance.

A: Custom jawline implants have many advantages over standard shaped implants, particularly those made of Medpor material as they are more difficult to shape during surgery. Medpor jaw angle implants, and medpor implants in general, have a higher risk of infection because of their porous properties than that of smooth nonporous silicone. Thus these implants must be handled with great attention to detail. The implants must be impregnated with antibiotics, and that is important and easy to do, but the far more important issue is adequate soft tissue coverage over them. This requires careful dissection of the tissue flaps over the jaw angles and great attention to a water tight closure. Having had two prior procedures before, this makes this pocket development and closure more challenging due to scar but, in my experience, can still be done very successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom facial implants. I currently have a jaw/chin implant in place which I want removed and replaced with a wrap around, custom made jaw implant (and possibly a cheek implant replaced). Is this possible to do as one surgery, I was diagnosed with a mild case of hemifacial microsomia, so my cosmetic procedures were focused on only one side. I had a single jaw angle implant placed on the left side, and 1/2 of a chin implant with an extending wing place on the left side as well. I also has cheek implants placed on both sides, and one appears to be much more prominent than the other post-op. All of these implants were done during one surgery, and I believe they are all silicone implants. I would like to create more symmetry and balance in my entire lower face, and provide more jawline definition while maintaining a feminine look (no squareness in the jaw, as the left is now). 

A: With your history of congenital facial asymmetry and an attempt using standard stock implants, the only way to really make significant improvement is to have custom facial  implants made. With the computer, all bony asymmetries can be precisely corrected and precision fit of the implants can be obtained. You probably have a very good result from the prior surgery but it just shows the limitations of using standard-sized implants for a face that is not normally formed. (asymmetric)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-surgical rhinoplasty. I am a 32 year-old female who does not like her nose. My nose has a dent and a crack in it. It has always been there as long as I can remember but as I get older it seems to be getting worse. I am scared to get a surgical nose job because if I don’t like it I will be stuck with it. I know an injectable rhinoplasty is not permanent but it is less scary to me.

A: A non-surgical rhinoplasty, also called an injectable rhinoplasty, is a quick and fairly simple procedure that can be done in about 15 minutes. The only type of nose problem that is amenable to injection are those that can be ‘cured’ by the addition of volume. These include a deep radix, a nasal hump, indentations, depressions and some minor drooping tips. While almost any of the current injectable fillers can be used, it is safest to use a hyaluronic-based filler (e.g., Restylane, Juvederm) as it has good linear flow properties through a 30 gauge needle. There usually is little to no bruising and minimal swelling afterwards. The duration of the nasal correction will last as long as the type of injectable filler used, most commonly six to nine months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have done a lot of research regarding chin implant revision and your name keeps popping up. I have a very weak jaw line/chin and I have a medium middleman chin implant placed with the wings cut off. The surgeon had to go back in three times intraorally to fix protruding wings and misplacement. The implant is still very high up and pushing my bottom lip up. I also have permanent muscle damage to my lip. I have denting and scarring in my chin. My last surgery was 6 months ago. I would like my neck to be tighter along with a new implant. I would also like to see if a revision rhinoplasty would fit in my budget. I had nose surgery about two years ago. The surgeon performed a pinch rhino when I’m more concerned about the bump in my nose. It still looks quite bulbous, I would like a small petite nose. I have attached several pictures and the web page called real self with other pics and doctor’s comments. Thank you for your time.

A: From a chin implant revision standpoint, intraoral placement if not placed in the proper position low on the chin bone and screwed in, has a high risk of riding up high in the chin. To properly revise this implant, the questions are whether to keep this existing implant and properly position it (ideally now from a submental approach) or to change the implant to a different style. Since you have never had a proper assessment of what this implant offers due to its many revisions and still high position, that may be a hard judgment for you to make. I would suggest a submental approach with a new implant altogether, removing the old one at the same time.

From a nose standpoint, there is certainly room for improvement from both a better hump reduction and a shorter, thinner and slightly more uplifted tip with a revisional rhinoplasty. I have attached some imaging to show what I think can be done from where you are now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fractional laser resurfacing. I had acne scars on my cheeks and decided to get revision surgery. A plastic surgeon suggested dermabrasion only on my cheeks. This left the area hypopigmented, uneven texture, and raised in the form of hypertrophic scars. I’m under the impression I can’t repigment the area. I’m using retinA to even out the texture and have received kenalog injections to reduce the hypertrophic scarring. However, since the injections are localized, and the scarring is over a broad area, I’m not getting the results I am seeking. I read a post by you where you suggested CO2 laser followed by topical corticosteroids which I believe could flatten the entire area. I’ve attached pictures for your review. I’m not sure if you can get an accurate understanding of my situation from the pictures. Note: the indented area on the left side of my cheek is due to a kenalog injection. I’m hoping this will fill in with time. 

A: Fractional laser resurfacing would be my treatment of choice for broad-based hypertrophic scarring from a prior dermabrasion. To prevent any recurrence, topical sterioids should be used as soon as the area is healed after about 5 to 7 days. Their penetration is aided by the channels cut into the skin by the fractional laser ttreatment. Whether the indented areas from the kenalog injection will fill in over time depends upon how long ago they were done and how many injections were done. If more than three months after the injections you should consider spot fat injections into the indented areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a jawline implant. I had a procedure to correct my jaw prognathism and teeth malocclusion. The surgery included sagittal split surgery of the mandible and LeFort osteotomy of the maxilla. While the LeFort osteotomy went well, unfortunately the sagittal split surgery which the surgeon had perform on my mandible were not very satisfactory. I’ve consulted with surgeon regarding the condition of my mandible and they all unanimously agree that my mandible were overly cut which resulted in an uneven contour of my lower jaw. The lining of my lower jaw project an unusual angle which stick out near the middle of my jaw. I had twice use fat graft to augment the area to recreate the mandible angle jaw line. While I am quite please with the result, unfortunately my body absorbs the fat rather quickly. I am looking into a more permanent solution, Such as silicone and synthetic bone. So here are my questions

1) Can silicone implant be used as an alternative to recreate my over dissected jaw line without adding width to my face?

2) I understand that synthetic bone can also be use to recreate my mandible jaw line. Assuming if silicone can also be used to recreate my mandible jaw line, which one would you suggest is a better option in term of result, Synthetic bone or silicone implant?

3) I am aware that both silicone implant and synthetic bone have its fair share of complication and risks.  I am aware that both synthetic bone and silicone could to some degree absorb one own bone resulting in asymmetry.  I am also aware that infection is also a likelihood. Beside the complication which I already mention, is there any other associated risk with either silicone implant or synthetic bone.

4) Unlike silicone, synthetic bone will create a permanent result. Assuming if I am unsatisfied with the result or infection occur, it there any alternative revision method?

5) What is the risk of nerve damages with this kind of procedure? 

6) And finally could you please provide a detail explanation of each method? For example how would you secure the silicone implant to the mandible? Where is the incision site? How long is the surgery? etc.

Thank you for your time and attention. I look forward to hearing from you very soon.

A: Thank you for telling your surgical history and describing your mandibular problem and need for a jawline implant. Your bony defect is really an absence of the jaw angle area. This is confirmed by the successful, albeit short-lived, fat injection augmentation results. In short, you appear to have an indentation probably at the location of the vertical bony cut of the sagittal split osteotomy. While there are multiple methods to treat this bony jawline/jaw angle defect, without question the best method is a synthetic implant. One can argue that it could be comprised of either silicone or Medpor material (I have used both very successfully) but the key is the implant design. Adding vertical length in an appropriate shape is far more important than the material used to create it. Either way the implant is placed from inside the mouth (like the sagittal split as done and secured to the bone by screw(s) Unlike your description, I have not seen the complications of implant migration, lack of permanency or a high rate of infections. There is no risk of nerve damage from this procedure. It is one I have done that is very similar to that of replacing cut off or amputated jaw angles. The key is designing the proper implant shape which can be made to add length but not width. Ideally, it should be made off of a 3D CT scan to exactly mimic that of a more normal shape. At the least it should be handmade off of a model made from a CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a necklift question. I want to know why you can’t just make an incision behind the ears and pull the skin up. When I pul the skin back along my jawline all my wrinkles disappear. This seems like such a simple thing to do so why is a necklift not done this way?

A: You are basically describing how a necklift (lower facelift) is done. There are variations of where the incisions are placed around the ears and whether the deeper tissues are manipulated and tightened . When you use your fingers to create a ‘facelifting’ effect, here is the trick to see where the incisions must be placed. First, the finger traction test must be done right next to the ear not more forward along the jawline as that creates a false result with too much of a change. The fingers must be placed from where the point of pull actually comes from by the ears. Secondly, put your fingers in front of the ear as well as behind the ear and do the lifting. You will see that a far more effective change occurs in both the jowls and neck when the pull is done from the earlobe and upward. This indicates that all effective lower facelifts must have an incision along the front of the ear to create an adequate skin movement. How far the incision goes on the back of the ear is determined by the severity of the neck sagging problem. In short, you can not have an effective lower facelift by an incision limited to just the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in your temporal reduction procedure. My head is an unusual shape and size and increases in size above the the ears quite dramatically. Please see the pictures attached. Is there anything you can do to reduce he bulge and make it look more normal?

A: Temporal reduction is one of many head reshaping procedures to change abnormal contours. I can see from the pictures you sent that you have a very prominent bulge above your ears. This is caused mainly by the size and shape of the temporalis muscle. While many people think this is due to the shape of the bone, it is really mainly a muscle thickness shape issue. This can be dramatically changed and a near flat temporal profile above the ear achieved by temporalis muscle reduction. This is done through a small vertical incision above the ear. The prominent part of the muscle is released and removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in body contouring after weight loss. I have 2 very large, deep atrophy dents, one on each hip from kenalog injections. I have arthritis and fibromyalgia in my hips. The pain is unbearable, and has left me disfigured. I also have lost 100 pounds over the past 3 years and have bags of fat instead of breasts. And I have a giant stomach that is all skin and fat that hangs dramatically.

A: Body contouring after weight loss, also known as bariatric plastic surgery, is commonly done today. When one loses 100lbs or more, as often happens with successful bariatric surgery or great personal diet and exercise efforts, many expected body changes occur. The large stomach deflates and become an apron that hangs over the waist line, the breasts lose their volume and hand down onto the stomach like two empty bags of skin, and the once larger arms and thighs sag. These common extreme weight loss concerns are treated with extended tummy tucks or abdominal panniculectomies and sagging breasts are changed with full anchor scar pattern breast lifts with implants in most cases. By getting rid of these tissue overhangs, combined with the weight loss, back and hip pain is often lessened. At the same time the large hip dents, which have occurred as a result of subcutaneous tissue atrophy from the steroid injections, can be treated by fat injections or even dermal-fat grafts depending on its depth and degree of skin tethering.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m an Asian American and I’ve been thinking of a few cosmetic procedures to enhance my flat face and that is rhinoplasty and midface augmentation.I’ve decided to go with the midface first. Being that, I’d like to know your inputs on the area of my midface that needs to be augmented for a more chiselled, three-dimensional look. I know that there a few parts to the midface – premaxillary and maxillary area for the anterior cheek ( I may be wrong on that ). So with that being said, what would you say about having both paranasal and malar implants done together? (for the case that I may need both) Would that cause a great incremental change in my facial projection compared to just one procedure done?

A: In looking at your face, which is not atypical for many Asian males, you might consider a somewhat different approach. The best procedures for ‘pulling your face out’ (increasing midfacial projection is a rhinoplasty combinjed with paranasal implants. It is very difficult to give much definition to broad wide cheeks without burying the rest of the midface behind them. (making the nose look even smaller) Look at the imaging I have attached to see what effect is created by initially pulling the nose and its base out. With your specific facial shape, this is where the real value is in any plastic surgery for you. The cheeks can be enhanced by probably not in the ideal chiselled fashion that you seek, I don’t think that is realistic for your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to decide between a lip lift and a lip advancement. I am aware of some of the differences between the subnasal lip lift and the vermilion  lip advancement. I have read through the information concerning these two procedures on your website. As I understand it, both procedures will reduce the distance between the lower portion of the nose and the upper lip. However,  the vermilion lip advancement will result in an increase in vermilion show throughout the entire upper lip, while the subnasal will only lift the central portion of the lip. In addition, the lip advancement  requires an incision along the entire upper lip which will result in a scar that will most likely be longer and more noticeable than the scar underneath the nose from a bullhorn lift. I would like to know any other advantages/disadvantages concerning both procedures that I may not be aware of. Based on the photos that you have before you, I would like to know what your recommendation would be in my particular case.

A: You seem to have a good grasp on the differences between a lip lift and a lip advancement. The decision then for any patient is balancing the concern about the scar vs. the degree of improvement they desire. Unless one has an absolute pencil thin lip (in which only the vermilion advancement will be effective), many patients opt for the subnasal lip lift due to less scar concerns even though only the central part of the upper lip is affected. Doing a subnasal lip lift first does not exclude the option of proceeding later to a vermilion advancement if one finds they want a more significant result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some facial reshaping procedures. I am 54 and desire more of a heart shape to my face. It is long and not as feminine as I would like. My nose is a bit long and wide on the bridge (from the front esp.) Looking younger would be great, but looking more feminine and therefore prettier is my main goal. Wider temple area/distinct cheekbones, tighter jaw to neck angle, more of a right angle beneath chin-to-neck, and a feminine nose are some ideas I have. My jawbone has reabsorbed somewhat, according to my dentist. But I need YOUR trained eye to tell me how to accomplish my goal of looking more feminine, losing the chub underneath my chin, creating a prettier facial shape in general. Thanks so much for giving me the straight scoop.

A: In looking at your pictures and understanding your facial reshaping goals, I would recommend the following changes.

CHIN A V or triangular shaped chin implant augmentation with the objective or bringing your chin forward, which is short, but making it narrower at the same time.

NOSE An open rhinoplasty to narrow the nose from the bridge to the tip with some slight shortening and elevation of the tip with nostril narrowing.

CHEEKS Cheek implants that produce some a combined malar/submalar (shell) effect. This with the chin helps create more of a heart-shaped face.

TEMPLES Subfascial temporal implant to correct the hollowing and increase the bitemporal width.

EARLOBES I know you did not mention these but these seem a little bit and stick out and reducing them adds a touch of femininity to the sides of the face.

I have attached some computer imaging predictions of how I see these changes affecting your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a back of the head skull reshaping procedure for the back of my head. When I cut my hair everybody can see the lump so I’m very frustrated about that and I like to know about this procedure to see what can be done to make that bone reduced in size by in filling around it. I was born like this and it has been there as long as I can remember. What can you do to fill around that bone is sticking out to reduce that size so make it look better? Thank you!

A: Skull reshaping of the back of the head is common for many types of contour issues.  I believe the lump on the back of your head to which you refer is a variant of what I call the occipital knob deformity. This lump of thickened bone occurs at the confluence of the nuchal ridge line of the occipital skull in the midline. One could argue whether this bone is too thick or whether the bone that is around it is deficient, either problem of which makes it stick out. From reading your description, it sounds like your concept of contour improvement would come from building up the bone around it using a bone cement material. That is probably the most effective contour approach and would completely eliminate that appearance. That is a very straightforward procedure to do using about 30 grams of material through a small (8 to 9 cm) horizontal incision in the occipital area above the lump and could be done as a 90 minute procedure under anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision. I am a black 26 year old female. I got to know about your practice online. I had a vertical scar on my face as a result of a bottle injury from three years ago. The scar is on the right side of my face just below my right eye on the cheek. So last year I had a scar revision where the Doctor surgically cut out the scar and stitched it up linearly. it looked good after that but some months later it started widening with some areas being indented and other side raised. I want to visit your practice for a scar revision. My mother also has keloids on her body, about two on her stomach, one on her breast, another at the pubic area. It itches her a lot and she wants to have them removed. She has had it removed it before but it grew back so it is a keloid. I have attached a picture of my facial scar and pictures of my mother’s keloid.

A: Your previous failed scar revision by a simple linear technique indicates that an exact repeat of that type of scar revision will result in the same outcome. Your next scar revision should be more of a geometric broken line closure pattern so that it is less likely to widen again. With your mother’s obvious keloids and their history or recurrence, their excision should be accompanied by either steroid of 5FU injections to try and lessen their likelihood of recurrence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a unique form of brow bone reduction/reshaping. I am wondering if you can reshape the bone on the lateral superior side of my orbital rim through osteotomy. I was only able to find one instance of this procedure in medical journals. I have attached the article below and I have also attached photos of my current eyes and what I would like my eyes to look like after the procedure. I am also interested in forehead augmentation especially on the lateral sides but that is not something that is as important right now and can be discussed later. I am not concerned much about scars as long as I can hide them with fairly long hair. This is because without an eyelid crease, I get ptosis and the current eyelid crease is causing much discomfort.

A: You obviously have researched out the need/benefits of a lateral superior rim orbitectomy/reshaping procedure (variation of brow bone reduction) so the issue of whether it is of benefit to you I will bypass over.

I have performed this procedure several times and it is the ‘simplest’ form of brow bone reshaping/orbital rim modification that I know. This is because it is done through an upper eyelid incision (as opposed to most brow bone procedures which is done through a scalp or coronal incision) and the frontal sinus or intracranial contents are not close to this area so the bone is thick and can be aggressively reduced. So it can  be very successfully done just as you have shown in this ‘ancient’ Plastic and Reconstructive Surgery article.

The only caveat in an Asian patient like yourself is that I would have some potential concerns about using an eyelid incision due to adverse scarring and in the face of pre-sexisting ptosis. In addition, if you have an interest/need for forehead augmentation, this would be another reason to consider coming from above, addressing two problems simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty and want to know if it is better to have it done open vs. a closed approach. My nose has a big and wide tip and hump that I want changed. Does one approach offer a better result for my nose?

A: The question of whether a primary rhinoplasty procedure should be done with an open or a closed approach is an historic debate. When it comes to revisional rhinoplasty, there is no debate that an open approach is almost always better depending upon the nasal problem being addressed. But in an unoperated nose like yours (thick skin, bulbous tip, dorsal hump) the operative approach is largely based on surgeon experience and preference. But most rhinoplasty surgeons today would opt for an open approach because it provides a more complete assessment of the structure changes and the prevention of complications that can occur from these structural changes. (middle vault collapse, asymmetries, supratip defomities) Open approaches do tend to have more prolonged tip swelling but that is a small price to pay for a more exacting result long-term. Many patients are concerned about the  scar from an open rhinoplasty but an incision is this small strip of skin between the nostrils heals remarkably well and rarely can be ever seen afterward even on close inspection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an HTR cranial implant replacement. (or maybe one made of PEKK)  I suffering a stroke in April which required a decompressive craniotomy. The removed cranial bone flap was finally reinserted 6 weeks later but then it got infected which required a heavy course of antibiotics and subsequent removal of it. I am now seeking to replace it with an alternative.

I have been in contact with Biomet, and as far as my understanding goes, they are able to make an exact replica of my skull from an MRI image and also that the bone cells actually adhere to this material.  Please confirm.

If you could share with me your experience regarding these materials, including but not limited to length of time you have been performing this surgery, risk, success rate, recovery time, cost, risk of flying with a bone flap, how long I would be under your care, how soon I could anticipate the surgery and anything else that I may have missed, I would very much appreciate it.

A: My experience with cranial implants and HTR cranial implants specifically is considerable. Understand that PEKK is a different material and manufacturing process and offers no advantages in cranial implants in my opinion, most importantly it is not a porous material that creates interconnect porosity. I have worked with Biomet since 1991 on HTR-PMI and have done many cases since, both cranial and otherwise. The HTR material and its composition does offer excellent tissue ingrowth and direct bone bonding to it. (I did the original research in 1995 that substantiates those tissue effects to it) As a synthetic replacement for cranial bone, it offers the best material properties in my opinion. Of the many I have placed i have yet to have an infection or the need to remove one from any complications.

While I don’t know the exact location of his cranial bone flap loss, the replacement surgery is fairly straightforward. A 3D CT scan is obtained from which an exact patient model is made. From the model, an exacting HTR cranial implant is made. Surgery involves reopening the scalp incision and inserting it into position, which usually has a good fit and rarely requires any intraoperative modification. The implant is then secured into place by small plates and screws and the incision closed. Depending upon the size of the defect and the patient’s physical health, it could be either an outpatient or overnite stay at the longest. The patient could return home within 48 hours and there would be no problem flying with a new cranial implant in place. Neither implant or the small titanium plates and screws are detectable in airport scanners. (do not set them off)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of facelift or facial rejuvenation but just not sure what. Not sure what procedures I would need to get rid of wrinkles, sun damage, and acne scars. I have attached some pictures of my face so you can see how bad I look.

A: In looking at your face, one of the fundamental problems is the large amount of loose skin which is contributing to the appearance of so many wrinkles. Rather than the loose skin just hanging off the facial bones, some people like you have it just pile up on the face. This also makes the acne scars look worse.

With this underlying skin problem, there are two fundamental approaches to take for your facial rejuvenation. The ideal approach would be a two-stage treatment consisting of a  first stage lower facelift and browlift to get rid of much of the loose skin and to tighten the face. Then a second stage could be done of a full face laser resurfacing or deep chemical peel to smooth out more of the smaller wrinkles and lessen the acne scars as well. Such skin resurfacing can not be done at the same time as the facelift due to healing concerns of the skin.

The second approach, not as ideal, is to just do the facelift or the laser resurfacing. Both are beneficial and would provide some significant benefit by themselves without the other. But the result would not be the same as if both were done. If one had to choose just one, skin tightening provided by the facelift would be the best choice as the one treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue.  Can you help me decide between fillers and cheek implants?

A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.

Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be  a good test or trial if one is uncertain about whether cheek augmentation is for them.

The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.

Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.

When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty revision.I had my nose done twenty years ago. I have a boxy tip and I would like to shorten my nose . My nostrils are big and long. I want them short and round. I want a cute small shorter nose. I’m wondering if there is hope for me. Thank you.

A: When it comes to a rhinoplasty revision, there is always hope. The key to achieving a shorter or smaller nose, in just about any patient, is the thickness of the overlying skin. When the cartilaginous portion of the nose is reduced, particularly the tip, the overlying tip skin must shrink down to reveal the reduced length of the tip cartilages and the greater narrowness of the dome cartilages that has been created. In a thin-skinned patient, such as yourself, this is most likely to occur. In thicker-skinned noses the thickness of the skin often does not reveal the new cartilage shape very well as it may actually become thicker as it contracts, failing to show the details of what was done underneath it.

When the nasal tip length shortens, the shape of the nostrils will change somewhat. Instead of oblong vertically oriented nostrils, they will be shorter in length and somewhat rounder in shape.

Whether any of these rhinoplasty revision changes will create your ideal shorter nose is a matter of personal opinion, but it is fair to say that it will be closer to your nose shape goals that before. You do have the best nasal skin to make that possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a new procedure that I have read about known as a knee lift. I have ugly rolls of skin just above my kneecaps that I just hate. They make me look like I have old lady knees. I know there is a scar but I think that would be a lot better than what I have now. How is a knee lift done and what is the cost? 

A: Like all body areas, the knees do show the signs of aging. The constant flexion and extension of the knee eventually causes loose skin to appear in folds or rolls above the kneecap. These suprapatellar skin folds can also be exaggerated by the downward descent of the thigh skin which pushes down against the fixed skin on the kneecap.

A surgical knee lift involves the direct excision of these folds of knee skin and leaves behind a curved suprapatellar scar. The creation of this scar in a visible area is the primary reason why it is infrequently performed. This is done through a crescent-shaped excisional pattern. The key to creating the best knee lift scar possible is precise placement of the excision location and to not remove too much skin. Since the width and appearance of scars is highly influenced by the tension they are under. too much skin removal across a joint that repeatedly flexes will lead to a wide and very visible scar.

The knee lift is done under local or IV sedation anesthesia. Long-term suture support is needed to resist the stretching of knee flexion and to help keep the scar as narrow as possible. The knee incisions are taped and ace wraps applied. Patients only need to avoid bending their knees greater than 90 degrees for a month after surgery. Other than that ther are no specific physical restrictions.

For the woman who considers a scar trade-off better than unsightly knee skin rolls, the knee lift can be a very satisfying procedure. Whether done under local or IV sedation anesthesia, the total cost is in the $4000 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about brow bone reduction. I read your case study “Reduction of Prominent Brow Bones in Men” and was wondering what the cost would be to have a surgery done like this? I have a prominent brow bone and would like to have this feature removed from my face. How long is the surgery? What are the long-term effects of the surgery? Are there any medical conditions that could occur as a result of the surgery? 

A: Brow Bone Reduction surgery is typically a 2 to 2.5-hour procedure. The surgery is performed through a scalp incision way back from the frontal edge of the hairline. The outer portion of the prominent brow bone is removed and reshaped to create a flatter appearance. The procedure is highly successful with no known medical conditions or problems associated with the surgery. The only potential issues are aesthetic in nature, with the risk of asymmetry of the bones and some persistent forehead numbness (though both are uncommon). The cost of a brow bone reduction procedure falls in the range of $8,000 to $9,000. I would be happy to review any pictures you could send me to see how this procedure may be of benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some lip augmentation procedures. My lips are getting thin with lines above them and the sides of lips are turning downward. So I would also want to have lip enhancement like implants which are permanent. And a treatment to reduce the lines above my lips.  Can I have these procedures on the same day? I have attached some pictures of my lips close-up.

A: Your lip augmentation will require a composite of procedures to get the best overall result. You actually do have some reasonable vermilion height although the upper lip is thinner than the lower. Your upper lip is also very long. Putting these lip issues together the best approach for your upper lip is a subnasal lip lift (to shorten the length of the upper lip), lip implant (for permanent volume), extended corner of mouth lifts (to lift up the corners and to make the tail ends of the upper lip thicker) and laser resurfacing of the upper lip. (to reduce the depth and number of vertical lip lines) These combined lip procedures can be combined with a lower facelift which is commonly done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a large breast augmentation. I am  5′ 3”, 112lb, cup size 32 A. Would a 500cc breast implant be too big for me do you think? I know what look I want and I know there is some increased risk with bigger implants. I tried on sizers in the office with the Volumetric Sizing System and 500 did not look too big to me. But the number does sound big.

A: The concept of a large breast augmentation is somewhat of a subjective one. Everyone’s interpretation of what that means may be somewhat different. While the number of 500cc breast implants is a big number and on a small frame will certainly look big, the most important question is what you think about its size. If you have tried on sizers and feel that it it not too big, then it is not too big for the look that you want. The other thing that you have to look at is the base width of the implant and see how that compares to your natural breast base width. With a high profile breast implant you want to make sure that it does not exceed  your natural breast base with so the implants are not too far to the side. When the implants get too far to the side because of their base width, they will generally be considered too big.  If so, you should then consider dropping down to 450ccs or less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have bilateral implants for my top lateral teeth. I was born without my permanent ones. I had this surgery and the oral surgeon told me my bone was not thick enough for the implants. They did the implant surgery and then did graft work. I had a total of 3 den grafts which my body rejected all three. They said the next step was to use my own bone, by removing it from somewhere or growing new bone from my DNA in a lab and then grafting it. Also, my implants are slightly exposed when I smile big and I am very self conscious about this. I would like this fixed. I am also wondering if I can have this grafting  done with bone from my protruding chin. Is there a way they can reduce and graft in one surgery.

A: Your prior maxillary bone graft failures sound like it was allogeneic or cadaveric bone, which is commonly used and can be successful, is never as good as your own bone. Forget about growing your bone cells in the laboratory, use good stock bone grafts harvested from the nest donor source available…you!!

Small bone grafts can be harvested from numerous face and skull areas. Each graft probably needs to be less than 1 x 1 cm so using your chin is a real likely possibility for  for a donor source. Depending upon how your protruding chin is reduced would determine how the grafts would be harvested and shaped. Chin reductions (bone graft harvests) can be done from an interpositional intraoral osteotomy or from a submental vertical chin reduction approach. When you are using your own bone, it is imperative that it is harvested and placed during the same procedure.

The more practical limitation of using your chin as the donor source for maxillary grafting is whether your surgeon feels comfortable harvesting and reshaping the chin at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in liposuction of one thigh. I had an injury that created a large hematoma on my upper thigh and I would like it removed. (It is stable). The hematoma occurred when I fell off of one of my horses and he jumped on my leg a few times (also happened to the other leg, but not as extensively).  It tore my quad and created the “dent” that you can see as shadowing in the picture. The hematoma is behind that.  It has settled into the size that it is now.  My grandfather (retired surgeon), stated that he was most familiar with cases where they would evacuate the hematoma after it was non-expanding.  He may have outdated information, as he is 84!  If you have any other ideas for treatment, I would be very interested.  I also attached a picture a few days after the injury occurred.

A: Liposuction may or may not be what you are looking for. Large expanding hematomas may need to be surgically drained if they create a large pocket, but that is not what you had. You had generalized bruising through the thigh musculature which must be allowed to resolve on its own…which yours now has. Liposuction is never a treatment for a hematoma regardless of the type.

The dent that is now in your leg is the result of the initial hematoma due to subcutaneous fat atrophy. Between the initial trauma to the tissues and the breakdown products of blood, some fat loss has occurred and this is why you have the dent. (tissue loss) This is extremely common occurrence from large hematomas.

Fat management is the key to improvement in your thigh contour but there are two different approaches depending upon what you want to achieve. If you want the surrounding contour to be even at the level of the dent, then the surrounding thigh areas need to have liposuction down to it. If you want the dent to be built out back to the level of the rest of the thigh (as it was before) then fat injection grafting is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal reduction. (head width narrowing) Since I am a young child I haven had a serious problem with the shape of my head. It is almost totally flat at the back and bulges out quite a lot not just above my ears but at the whole temporal area, because of the permanently wrong sleeping position as a baby. Now I am 21 years old and my head width is 177-178 mm , while the average male human breadth is about 150-155mm (depends on ethnicity and height). I am 183 mm tall and in my whole family there is no such a case like me so that it is definitively no genetic reason for that excessive width. Furthermore there is an asymmetry as the right temporal region sticks out for about 3-4 mm more than the left side, so that when I haven’t long hair it can be seen. Now my two questions:

1) Is it possible to reduce the temporal region in order to make it more acceptable ?

2) How much would it cost as it is not just a small bulge but an area with about 40 to 50 square cm on each side? I have attached pictures of my head with line drawings so you can see what I am talking about.

A: Temporal reduction can be an effective head narrowing procedure in the properly selected patient. A bulging side of the head is made up of a combination of temporalis muscle and temporal bone. While many perceive that the problem is too much bone, the reality is that more than 50% of any temporal convexity is muscle. The smaller the amount of temporal convexity, the more that the attachment and thickness of the muscle is the problem. Your pictures show a mild to moderate temporal convexity (in my experience) which indicates to me that a muscle reduction/shortening would be an effective solution.

When it comes to temporal muscle reduction, there are two approaches…injectable Botox and surgical reduction. Botox injections can work for permanent reduction in the thickness of the muscle and has the advantage that it can work on any area of the muscle. Its disdvantage is that the result from its use take time, require multiple treatment sessions and may not work for everyone. Surgical reduction produces an instantaneous result by permanently and immediately removing a portion of the muscle. Its disadvantage is that it does require small vertical incision and can not reach all areas of the muscle.

When you look at your side diagram with your drawing, surgical reduction can reach the back half of that drawing but the thickness of the muscle at the edge of temporal hairline and in the non-hair bearing skin to the side of the eye is beyond what surgical muscle reduction can reach.

Based on your temporal areas of concern, you could either try a series of Botox injections or combine surgical reduction with Botox injections for the most forward part of the temporalis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom facial implant (jawline) revision. One month ago, I had a custom wrap around jawline implant placed which is way too big and disproportionate to the rest of my face. I think that it should be removed or at least reduced in size as soon as possible. Is this possible at just one month after surgery?

A: Let me first provide you with some comments about a custom jawline implant that come from a more objective perspective. I have done many standard and custom implants for young men and there is almost always a fairly standard pattern of postoperative behavior and anxiety in the early postoperative period….many think the implants are too big/asymmetric/not right and want it immediately downsized/revised or even removed. Sometimes this is true but most of the time it is because the patient has does not have an objective perspective and is finding it difficult to go through adjusting to their new look…even if it was exactly what they said that wanted. This is a phenomenon that I call Facial Structural Accommodation. I would urge you to be more patient with your result, not because a great amount of swelling resolution is going to make it smaller, but because you need time to let the result soak in. Oe month is simply not long enough to really know. Doing something now may be very capricious and a decision you may come to regret later. While I obviously don’t know what you looked like before or after this surgery, most men that I have seen in similar situations rarely have an after surgery result that would be objectively viewed as way too big.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to change the look of my face I am 20 years old and am very desperate about my appearance. I want to change my facial features like someone else, like maybe a 60% look like that person. I am willing to change my ears and eyes. Is it possible?

A: As a general rule, It is not usually possible for anyone to look like someone else regardless of how much plastic surgery they have. (although there are clearly documented instances where this is not exactly always true as a few people have spent have spent a lot of money on so called celebrity makeovers)  Having said that there are instances where substantial improvements/changes to a face can be made (perhaps a ‘60% look’) based on how close one looks like what their ideal face is. In some cases there may be just a few facial features that is the real difference between two faces and changing these may make that ‘60% look’ possible. I would have to see pictures of your face and your ideal face to see whether such changes may be possible. You have  mentioned the eyes and ears so I am assuming you see these areas as the biggest changes needed.

Dr. Barry Eppley

Indianapolis, Indiana