Your Questions

Q: Dr. Eppley, I am working on a story and wanted to get a quote from you in regards to mouth lift surgery. What are your thoughts on people who are having it at a young age – are there pros and cons? How serious is the operation? What is the  average age for this procedure? Does it make a difference on Asian patients?

A: Corner of the mouth lift surgery has been around for a very long time. It was introduced over fifty years ago, long before facelift surgery was widely done. It was developed to treat the downturned corners of the mouth that develop from aging as the facial tissues sag. This facial droop pushes down on the mouth corners changing a horizontal smile line to an inverted smile line (at rest) in some people. The corner of the mouth lift was done to directly remove the overhanging skin and lift up the commissures. (corners of the mouth) It is a very effective small procedure that has not really changed over the years. Despite its history, it is not well known and many think it is a new surgery.

A corner of the mouth lift is a very simple procedure done in the office under local anesthesia. There is virtually no recovery other than having a few small sutures for a week. While it is incredibly simple to do from a plastic surgery standpoint, it is a very technique sensitive and delicate procedure in which the design of the cutout must be very carefully done to achieve a good result and not have any adverse scarring.

As you could surmise by its history, the corner of the mouth lift is traditionally done for patients who have general facial aging concerns. (usually greater than 45 to 50 years of age) But I have done the procedure on much younger patients (as young as age 16) who naturally have downturned corners of the mouth or corner of the mouth asymmetry. (one corner turned down, the other one normal)

As you have mentioned Asian patients, you may be referring to the recent internet story on the ‘Smile Lipt’ procedure out of Asia. This is just the traditional corner of the mouth lift done to give patients a permanent smile or mouth curls, often it appears on younger patients. By American standards, the Asian mouth curl result would be considered unnatural and exactly the ‘complication‘ from a corner of the mouth lift that we would want to avoid. But this is just the fashion and beauty differences between countries with very different cultures. You may read more about this in my recent blog story entitled ‘The Global Differences in Corner of the Mouth Lifts’.

Dr. Barry Eppley

Q: Dr. Eppley, I am interested in breast augmentation and possibly breast lift. I live in Minnesota but my best friend lives in Indianapolis and she suggested you. I am wondering is I were to come to Indiana for the surgery if I could have a consultation with surgery the following day. Also, being from out of town, how often would I need to be rechecked?

A: There would be no problem with scheduling surgery and just having a consultation the day before. That is a common occurrence in my practice as we see patients from all over the world every week. To make that happen effectively there are certain breast augmentation questions that should be answered in advance. They include the following:

1) Are you interested in saline or silicone breast implants?

2) Are you interested in round or shaped (anatomic) implants if you prefer silicone?

3) Do you have an incisional preference for placing the implants of lower breast fold (inframammary) or axillary (armpit)?

4) What size result do you want? (pictures are helpful here of breast augmentation results you like)

5) What is your height, weight and current bra size?

6) Do you have any breast sagging? (this is a very important as if so a breast lift may be needed with the implants)

If you have the ‘perfect’ breast for augmentation (no sagging, nipples locate well above the lower breast fold) then presurgical photos may not be necessary. But if your breasts may be less than perfect or have known sagging, please send me some pictures of them so I can know in advance as to what you exactly need.

As for follow-ups, I like to do phone, Skype or Facetime conversations to accomplish that for my far away patients. Between pictures and e-mail communications, all the follow-up that is ever needed can be done at a distance. From these we can make the determination if you ever need to come back and be seen by me in person.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was in a bad car accident over 15 years ago. I had a tracheostomy to enable me to breathe. But it has left a terrible scar. Growing up through high school, college, and even some times today; people tease me about having a “hickey.” Also even children who I do not even know will point to me to their mothers after they see me because they notice the scar on my neck. I am tired of being teased by people I know and even young children who do not even know me at all. Would I be able to have tracheostomy scar revision to remove the scar. (The doctor “fashioned” the scar to look like a cross but since it’s over 10 years old, the scar does not resemble a scar. 

A: I think there is no doubt that your tracheostomy scar had a lot of room for improvement. I would not use the term tracheostomy scar ‘removal’ as that would be impossible to never have any scar on your neck. But minimizing it is the realistic goal so the proper term would be tracheostomy scar revision or tracheostomy scar reduction. This would require complete horizontal scar excision, surrounding skin underming, possible dermal-graft placed underneath and then a linear layered closure done. While initially his would be just a fine line scar, it would take a few months to see if any scar widening developed. (although never to the degree that you have now) One should even think about a second stage revision or laser resurfacing for optimal improvement should the scar become a little wide although I would hope this would be unnecessary. This is a procedure that could be done general or IV sedation an an outpatient procedure. There essentially is no recovery from it other than scar healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to thin out my large African-American nose, add a defined bridge and still look “natural”? How long does surgery take and how long is recovery?

A: Thank you for your inquiry and sending your pictures. The African-American rhinoplasty is unique  because of the very thick overlying skin and lack of a strong bone or cartilage framework underneath it. You are correct in your description of how to approach the broader and flatter nasal structure by dorsal augmentation (usually with an implant), increasing tip projection with definition with columellar strut and tip cartilage grafts and nostril narrowing. I have done some computer imaging to show some of the potential outcomes with are highly controlled by the thickness of the overlying skin and how well it can contract down over a new supporting framework. The first  imaging prediction is based on the least amount of change (thinning) that can occur while the second imaging prediction is based on what I believe to be the maximum change that can occur in a single rhinoplasty procedure. You did not provide a side view image so how that would be affected will require a profile picture. I will let the images speak to your assessment of whether such a result would be natural in appearance.

This typical African-American rhinoplasty usually takes about 2 1/2 hours to perform under general anesthesia as an outpatient procedure. Since internal breathing work does not need to be done (I am assuming) nor do nasal osteotomies or a rib graft harvest (since an implant would be used), there should be minimal pain afterward and no bruising. Recovery is more about how you look having to wear external nasal tapes and a splint for a week after surgery. Once that comes off there are no physical restrictions and one’s appearance should be socially acceptable. While the final results of a rhinoplasty can take six months to fully appreciate (maximal skin contraction and thinning), one should be reasonably comfortable returning to work and socializing again in 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I will be turning 20 later this year and I was wanting a more thicker appearance at the top of my breasts. I’m fine with my chest area I really wanted to get a fat transfer I really don’t want the implants but if I would need to I could.Thank you.

A: Whether you are a good candidate for fat injection breast augmentation depends on the size and shape of your breasts  and what your breast augmentation goals are. You describe the goal of ‘thicker appearance at the top’ which I interpret as just wanting more upper pole breast fullness. Given your young age and this smaller type of augmentation, fat injection breast augmentation may be a reasonable option instead of implants for your needs. However, whether you have enough fat to harvest, how much fat graft volume is needed and whether this would require more than one injection session are issues to be evaluated before determining if fat injections can achieve your aesthetic breast goals. We know that a small breast implant can achieve that goal successfully and in an efficient manner, the question is whether fat can do the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been told by another physician that infraorbital rim implants would benefit me.  I have dark circles that have really been developing a lot under my eyes and have had Restylane with little effect (just one treatment).  I am hoping for a more permanent solution.  Do you agree it could benefit me?  Can this procedure be done under local anesthesia?  What is the approximate cost of this procedure?  I have attached my photos.

A: I would agree that you are a good candidate for combined infraorbital rim-malar implants given your anatomy and the lack of success with injectable fillers. Both your cheeks and your lower orbital rims are retrusive in position. From the side view you have a negative vector, meaning the cornea of your eye sticks out further than the cheek-lower eye socket bone. This is an anatomic sign that bony augmentation may be aesthetically beneficial. The placement of orbital rim implants can be done in two ways, either through a lower eyelid incision (preferred) or from an intraoral approach. Better implant placement and less risk of injury to the infraorbital nerve is ore assured with a lower eyelid approach. Either way the procedure can NOT be done under local anesthesia under any circumstances. The approximate total cost of the procedure is around $6500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m doing fine after my facelift surgery except for one big problem.  I have a serious issue with bladder control. I’m constantly feeling the urge to urinate and can expel just small amounts to less than a dibble. It’s been uncomfortable. Any ideas on how to re-regulate this?

A: I am not a Urologist but your after surgery issue is not the first time I have seen it. Urinary retention after surgery in older men is not uncommon, particularly if they have a known or unknown enlarged prostate gland. Usually the problem is treated by the use of a catheter which is passed into the bladder to allow the urine to empty. Initially a one-time (in and out) catheterization is done. But if the bladder fails to continue to empty properly, a catheter may need to be replaced and left in a for a few days. There are no medications that have been proven to be helpful for urinary retention although drugs such as cholinergics and sedatives have been tried with variable results.

You do not want to go for an extended period of time with bladder over distention. Based on your comfort level and how much (or little) urine you are getting out, a visit to the local emergency room may be in order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in liposuction surgery. I have never been terribly overweight, however, I can’t lose the belly fat. I would also like to take a few years off my face. Most people tell me I look to be about 45, I’m actually 56. My looks probably matter more to me than most people as I currently work in a very visible public position so I feel I need to look my best so I can stay in this business until I retire. I would like to know what I can get done and not have to be off work any long periods of time. I am very interested in liposuction of my stomach/butt/thighs/ and arms, possible facial work later.

A: Since body contouring (liposuction) in your primary focus for now, I will keep my comments to that area. The most important question based on your inquiry is what is the best treatment for your body fat concerns. The abdominal area is always the one body area where the debate is between liposuction and a tummy tuck. It has been my experience that most people assume that liposuction can do too much, that it can magically remove a lot of fat and tighten up a lot of loose skin. While liposuction is a very good fat reducer, it can do little for excess skin. Thus whether it is an appropriate surgical method for your abdomen, arm, thighs and buttock issues will require a physical examination to answer. My concern for you is that the desire for great body contour changes and little time of work often do not go together very well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a way I can find out more about the rib cage narrowing you have posted on your website? I am interested in this procedure and would like to know more about how it is done, costs involved, and recovery time. Thank you.

A: Ribcage narrowing, also called waistline narrowing surgery, is done by removing the 9th and 10th cartilaginous ribs (and occasionally the 8th) to make the waistline vertically longer and narrower from the sides by removing the bulges of the ribs. It is a procedure that may be effective for some patients based on their anatomy and if they are already fairly thin. It is done through a 4 to 5cm incision directly under the rib cage on each side. One has to carefully balance whether the thin scars are a good trade-off for the result. Recovery is solely based on the level of discomfort and is, of course, quite similar to traditional rib graft harvesting for rhinoplasty or mandibular reconstruction with the exception that it is done on both sides. Immediate pain management is aided by the use of rib nerve blocks and infiltration of long-acting local anesthetics into the rib and abdominal musculature. It is done under general anesthesia as an outpatient. The total cost of the procedure is around $6500 – $7500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Dr. Eppley, why is my abdomen and waist so hard after two weeks, sore I can understand. How long before it gets back soft. Further when can I stop wearing the garments they are so uncomfortable. Can I take an over the counter drug to help the with swelling or what can I do to help the hardness HELP PLEASE

A: Liposuction is a very traumatic procedure to the tissues that results in swelling, induration and a scar-type reaction. Every liposuction patient, regardless of the technique used, will have to endure a period of swelling and tissue firmness. This is normal and to be expected. The two go hand in hand and both resolve slowly. It is a natural process that takes time as lymphatic drainage is restored. Tissues will return to a normal feel as the soreness and numbness passes. While it will get better as each week goes by, expect a return to complete normalcy of up to a minimum of 6 weeks and possibly as long as three months. There is nothing you can do to hasten that process along such as any OTC medications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have medpor chin implant that was put in 6 years ago intra-orally. The implant is a bit big for my liking, making my chin look a bit too boxy and masculine, and the projection from the side is too much.   Can this implant simply be shaved down rather than completely removed?  And if it was inserted through the mouth, does that mean it would have to be approached from the outside?  Thanks so much for your expertise.

A: Trying to shave the existing implant in place will usually end up with an undesireable result. If one wants to modify an existing implant, it is always best to remove the implant, modify it outside the patient and put it back in. Since medpor implants are quite adherent to the tissues, removing them almost always requires it to be done in pieces this virtually destroying the implant. It would be better to figure out what the proper dimensions of the chin implant that are needed (based on what you know doesn’t work well) and remove the existing implant and replace it with a new one that has the desired form. Most women need smaller more triangular chin shapes (less boxy) and many chin implant designs are really made more for men.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 1.  Am interested in an overall approach to address my weak jawline/chin and nasolabial folds. I had a smaller chin implant over 20 years ago, but I am certain that advances since that time could provide me with a better overall result.

A: I have received your pictures and done some initial imaging predictions. Knowing that you have a chin implant in place with your high jaw angles indicates how short your lower jaw really is. Substantial improvement can come by changing all dimensions of the jawline, not just the horizontal position of the chin. There are two fundamental approaches. A sliding genioplasty combined with an extended chin-jawline implant overlay with vertical lengthening jaw angle implants is one option. The second choice would be a custom total wrap around jawline implant made from a computer-generated design off of a 3D CT scan. There are advantage and disadvantages with either method. Either approach takes it way beyond what the simplistic approach of ‘chin augmentation’ would achieve by looking at a complete jawline enhancement. As you know, your lower jaw issue is not just a simple isolated chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had all my stiches break open (only left side) 1 week after my cheek implant surgery so my left cheek got infected. I was in pain with swelling. The Dr .chose to do revisional surgery in his office where he took the implant out, sterilized it and flushed my cheek out with a liquid then put it back in and stitched it up again. I was on two antibiotics and right away the pain stopped and some swelling came down. My problem is that at 4 months out I noticed my cheeks were not matching up! From the top were the malar implant was put is fine but the bottom looks swollen on that problematic left side. The right side is thin and slender but the left looks like a ball especially when I smile. I talked to the Dr and all he offered was some lipo and acted like I always had that there. I know my face and it was never there before. My question is what test would you recomended to figure out why the tissue on one side of my face different from the other. The tissue is soft and squishy not hard. I’m worried this still has something to do with it being infected.

A: The two possibilitues are that this is excessive scar tissue that would commonly form after an infection. I doubt that it is an infection now since you know what that feels like. The other possibility is that the implant on the infected/revised left side is sitting lower or in a different position than that on the uncomplicated right side. I would suspect it is the latter and not the former. The definitive answer would be to get a 3D CT scan which would show the exact location and symmetry between the two cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about genioplasty, I hope you can help me. Is it normal to feel the screws after a genioplasty? (I refer to touch the chin with the fingers) If you can feel the screws is it a bad thing? Can screws create volume on my chin? In this second genioplasty the chin was vertically. (5mm) This is my 7th day after surgery
but I’m worried because just touching my chin, I can feel the screws. Does that mean my surgeon did a bad job? Any solution for this? In the first genioplasty never had this experience but that surgery was just a horizontal cut.

A: The only circumstances in which screws after a genioplasty can be felt is if there were placed in a lag screw fashion where the screwheads would be on the edge of the advanced chin bone in a horizontal cutr or if the chinb was vertically lengthened and the inferior location of the plate and screws may be at the bottom edge of the bone. The fact that you feel them is harmless. They can not create more chin volume per se. It just means the location of the plates and screws may be palpable, that is not harmful or dangerous. After it heals (one year) you can have them removed if it continues to be a concern for you.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have never been terribly overweight, however, I can’t lose the belly fat. I would also like to take a few years off my face. Most people tell me I look to be about 45, I’m actually 56. My looks probably matter more to me than most people as I currently work in a very visible public position so I feel I need to look my best so I can stay in this business until I retire. I would like to know what I can get done and not have to be off work any long periods of time. I am very interested in liposuction of my stomach/butt/thighs/ and arms, possible facial work later.

A: Since body contouring in your primary focus for now, I will keep my comments to that area. The most important question based on your inquiry is what is the best treatment for your body fat concerns. The abdominal area is always the one body area where the debate is between liposuction and a tummy tuck. It has been my experience that most people assume that liposuction can do too much, that it can magically remove a lot of fat and tighten up a lot of loose skin. While liposuction is a very good fat remover, it can do little for excess skin. Thus whether it is an appropriate surgical method for your abdomen, arm, thighs and buttocks issues will require a physical examination to answer. My concern for you is that the desire for great body contour changes and little time of work often do not go together very well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in enhanced fat injections, but was told by a doctor that it was no longer allowed but see you are discussing it so you must be using it. I have a couple questions. I had a lumpectomy nine months ago with radiation. Can not get implants so I am looking at fat injections to fill the hole and add some volume as my beasts are quite small. Is this a procedure you would recommend for someone in very good health and 69 years old? Can injections be done on my other breast to increase volume?

A: The term ‘enhanced’ fat injections can have various meanings. Some use the term to simply refer to liposuction-harvested fat that is  concentrated and then injected. Other interpretations refer to actually adding a stimulant to concentrated fat such as PRP (platelet-rich plasma), stem cells or even insulin. I prefer to use this latter definition of enhanced fat injections as adding something to the concentrated fat.

Currently no one really knows if adding any agent to concentrated fat is helpful in creating better fat survival but it remains biologically appealing. The addition of stem cells to fat is the most intriguing and captures the greatest public interest. But the harvesting of stem cells, growing them in cell culture and putting them back into a patient is not presently permitted by the FDA unless it is part of a sponsored clinical study. (as no one knows what such concentrates of stem cells will really do) Fat, by its composition, already has a lot of stem cells so every fat injection is technically already ‘enhanced’ to some degree.

Since the addition of extra stem cells is not permitted, I prefer to add PRP to smaller volume fat injections. PRP is an extract of your own blood that contains platelets which are full of various growth factors. These have well known stimulant properties on wound healing, take a few minutes during the procedure to harvest and concentrate and are easily mixed in with fat.

Fat injections are an excellent treatment for lumpectomy defects particularly in tissues that have received radiation, regardless of the patient’s age. While fat can also be injected into breasts for general volume enhancement, the success of that breast augmentation approach depends on what your breast currently look like and what result you are expecting to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if a jaw surgery can correct my facial features. My jaw appears to start almost directly from my ears and angle downwards instead of forwards like you see in pretty people. My face is long and narrows towards a tiny recessed chin.  Actually, the lower third of my face angles backwards. My chin is slightly bumpy with my mouth closed, and very bumpy when I stick my bottom lips out. I have no bite problems since I’ve had braces when I was a teen (spacers for crowded teeth and a hyrax to expand my upper palete, but no headgear or tooth removal) I’ve heard that orthodontics can lengthen the face and lead to a recessed chin and humped nose over time. I’m not sure if my braces caused my facial problems or if it is genetic because my dad also has similar facial features and also had braces when he was younger. Is there a jaw surgery, or perhaps multiple surgeries that can fix the angle of my jaw and also my recessed features?

A: Your pictures show a classic case of a short lower jaw with a small chin and a high jaw angle. Your chin also shows a mentalis muscle strain which is why it is bumpy. (muscle fasciculations) Since you have no occlusal disharmony (bite problems), jaw surgery (moving the entire jaw forward) can not be done. Even if your jaw was moved forward the high jaw angles would not be changed. (the chin would be corrected however) The proper treatment for you now is a combined sliding genioplasty (moving the chin bone forward) combined with vertical lengthening jaw angle implants. This combination puts the shape of the lower jaw in better balance. (chin comes forward, jaw angles drop down)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Do you ever harvest fat from the pubic area for breast inhancement? I had smart lipo done on my abdomen and bra roll area. I have excess fat in the area of my pubic bone and inner thighs. I also have a small hump on my back below my neck. I am a young 64. I have execised and taken care of my body. My breasts are ok, they just need some filling out on the top to give me more cleavage.I have good elasticity. I also had smart lipo on my breasts about 10 months ago. They have lifted 2cm. I would be interested in an arm lift in the future.

A:When it comes to getting fat injections placed elsewhere in the body, particularly for the breasts which will require some volume,  you get it wherever you can. The pubic area can be a rich site for fat often offering as much as 100cc of good fat. That area combined with your inner thigh and knees may be just enough to get at least 200cc of concentrated fat for each breast. The arms would be another potential site of harvest since you may be gettings armlifts in the future anyway (as you have mentioned) and creating some skin laxity is not a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question. I had a chin implant done on Aug 6th and I am experiencing lower lip and chin numbness on the left side. My smile is not the same as it was and I am starting to get concerned. The numbness is my real concern as it is driving me crazy. I don’t know what to do and I am becoming depressed. I am only 22 years old and I do not want this feeling for the rest of my life. Do you think it will go away? Should I get the implant removed or will this cause more injury to the nerve? Please if you could get back to me I would really appreciate it.

A:  The recovery from chin implant surgery is almost always more significant than patients realize or have been told. (or what they have heard when the recovery part is discussed with them) It takes a good 6 weeks for about 90% of the recovery to have occurred. Chin stiffness, distortion, numbness and a lower lip or smile that is not normal is all part of the recovery process. Given that you are just one week from surgery, your concerns are way premature and you need to let the process work itself out for 4 to 6 weeks after surgery. Most of your current issues will either be gone or be well on the way to recovery that you will likely be happy than you had the procedure. Your lip numbness would be more concerning if it was still present in its current degree without any improvement at six weeks after surgery

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheekbone reduction using the L method. Now cheeks are really low. I want to ask can you put an implant on top of the cheekbones which have been cut and screwed in a lower position? Or is this not possible as it may make the already cut cheekbones move position or fall off??

A: Your cheek bone prominence can be restored by the placement of an implant on the cheekbone. Even though the face of the cheekbone has changed, cheek implants are screwed into position so there is no chance of shifting or falling off of the face of the cheekbone. Having a prior cheekbone reduction does not preclude the placement of cheek implants later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have you ever treated sufferers of migraines caused by (likely) the hard throbbing of the superficial temporal artery. My wife has 5 migraines a week, nearly all of which are in this area. We do not understand the root cause of the pulsations themselves, but it is possible these hard pulsations (lasting hours, or even days on end) are irritating the nerves local to the artery, and becoming interpreted as migraine in the brain. Given that medications (and neurologists and others) offer no relief, and she has suffered for decades, we are exploring procedures. Thank you.

A: While getting to the origin or even finding an effective treatment for migraines is never simple, the simple answer to your question is yes. It is very possible that high flow through the superficial temporal artery (STA) can be a source of migraines. While I would have initially thought it was possible but with a low probability, I recently treated a lady with a 30 year history of refractory migraines of the right temporal region with 2-point ligation of the STA with a dramatic and sustained reduction of her migraines. She felt that the pulsations she was feeling was a major contributor to her migraines and the origins was clearly on the temporal side with very visible pulsations. Given that there is no risk of any downside to STA ligation and it is a minor procedure with no recovery, it seemed like a reasonable thing to do.

While there would be no guarantee that STA ligationswould be effective for your wife’s migraines, and they should always be done from two points to eliminate recurrent pulsations due to retrograde flow, it would be relatively easy to eliminate this potential source.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know the differences in the frontal view after orbital decompression and brow bone augmentation? I would like to get deeper set eyes but I know decompressions has a lot of side effects. Do you have photos of before after to show for brow bone augmentation? Thank you

A: Orbital decompression will not produce deep set eyes in a normal patient. While orbital decompression is effective for the patient with protruding eyes (exophthalmos), this is because it is an abnormal protrusion and dropping out the orbital floor bone will give the enlarged eye a space to fall back into. In the normal non-enlarged eye, dropping the orbital floor will only make the eyeball fall lower and not back. Thus in the frontal view, the eyeball may look lower and the pupil drops down closer to the lower eyelid margin. Conversely, brow bone augmentation combined with lateral orbital rim augmentation will make the eye look deep because it moves the bony rims around it further forward. This can be shown by looking at before and after pictures of brow bone/forehead augmentation which can be seen on my website in the Facial Reshaping section under those specific procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if the implants that you use to replenish the infraorbital eyelids are the same used for the cheeks or are this special for this area? Last year I had put some implants under my eye this were the regular implants for the cheek but the doctor cut them to reduce them. My problem is that my skin is very thin under the eye and the implant shows the edges and feels hard so it looks and feels unnatural. Please tell me if there is a remedy. Maybe the implants you use look more natural.

A: One of the important issues with infraorbital rim implants is their positioning along the inferior orbital rim. Depending upon the aesthetic purpose, they may be used to provide more horizontal projection to the bony rim but still stay below the edge of the bone or they may be used to treat under eye hollows and are raised above the level of the bony rim. Depending upon their size and shape of the implant there is the risk of palpability of the implant edge. More uncommonly there is also the potential for actually being able to see the implant edge through the thin skin of the lower eyelid. I don’t know what type of implants you had placed (Medpor vs silicone) or exactly where on the bone they are located. If standard cheek implants were used and then modified for the infraorbital rim area, it would be unlikely they would have perfectly smooth edges. Based on just your question alone, the remedy may be to have implants that are actually made for that facial bony area.

It would be helpful to have some more information, such as a picture of you showing exactly where the edge of the orbital rim implants are that you feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old. My question is in regards to my face which is crooked. It does not have the best shape. The right side of my face is not equal with the left side. (see attached picture) Because my face does not look good, I have no confidence. Please suggest to me what I am supposed to do.Your advise is highly appreciated.

A: Your picture shows that you have significant facial asymmetry. The left side of your face shows hemifacial hypoplasia (hemifacial microsomia) as demonstrated by significant left chin deviation, a flattened left cheek and an inferiorly positioned (low) left eye and eyebrow. There are a variety of facial plastic surgery procedures that can help improve your facial asymmetry. Beginning from the bottom of your face and working up, the chin can be brought back to the facial midline by a sliding genioplasty, the left cheek built up by an implant, the eye raised up by an orbital floor implant with repositioning of the left canthus (corner of the eye) and the lower brow lifted by an endoscopic browlift. While all of them done together will produce the best degree of facial symmetry improvement, treatment of the chin and cheek asymmetries are the most important as well as the most improveable of the facial deficiences.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had an injectable filler treatment done for my hollows under my eyes. Besides a few lumps there is one lump that actually has a bluish color to it. I thought that it may be because it was bruised. But three weeks after he injections it has not changed. What is causing this coloration and will it eventually go away?

A: You undoubtably were injected with one of the hyaluronic acid-based injectable fillers which is the most common one used in the thin skinned area under the eyes. What you are seeing is known as the Tyndall effect, a well known phenomenon from injectable fillers which can be seen when they are placed right under the skin too superficially. Because the injectable fillers is really a colloid and not a solution, there are large molecules of the hyaluron chains that are floating around in the gel solution. When injected too close to the skin the superficially placed filler material allows light to be scattered off of the floating particles. It appears blue because only the scattered longer wavelength blue light is reflected back to the viewer while other light wavelengths are less scattered. While aesthetically disturbing it is not harmful and will eventually resolve itself as the material absorbs. Because filler can last a very long time in the eyelids, you may consider hyaluronidase injections to help it dissolve much sooner than its expected implantation duration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently had a medium Terino style 1 chin implant and medium lateral jaw angle implants, with another surgeon. I wasn’t happy, and I had the jaw implants removed a week later. For some reason the 2 implants didn’t seem to go together, the jaw implants made my chin look like it was recessed again, and the sides of my jowls looked very narrow, even though they improved the back of my jaw. I now wonder if it was the chin implant I should have removed and replaced instead. I wonder if it was the combination of sizing that was the problem, I want to have a strong jaw that flows all the way to the back. I have a thin face and the sides of my chin, near the corners of my mouth, still look very  narrow. What could be done to solve this problem? Thanks

A: Standard chin and jaw angle implants rarely overlap and, even if they do, will rarely ever make for a straight jawline from chin to jaw angle. That is beyond what they capable of doing. When a patient agrees to have off the shelf stock implants they should know that is the look they can not achieve. Only a custom-designed one-piece jawline implant will provide a straightline effect from front to back because it is made to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my husband had maxillofacial surgery for an under bite and put cheek implants in to balance his facial features about five years ago. He has had problems with the left cheek implant moving slightly and when he blows his nose his left cheek gets swollen and you can feel bubble like things moving around implant. It has caused him a lot of pressure and pain and this happens more often. I have begged him to go to the Dr but the entire experience of the surgery has traumatized him and so I’m trying to figure out what’s wrong. Please help me try to help my husband.

A:  Undoubtably what your husband is experiencing is what one may call a ‘blowhole’ in the simplest of terms. When a maxillary osteotomy (LeFort I osteotomy) is done, the bone cut across the upepr jaw exposes the entire maxillary sinus. While most osteotomy lines experience complete bony healing afterwards, some do not particularly larger maxillary advancements and those that may have been vertically elongated. Any large unhealed bony openings allows air to escape from the maxillary sinus up into the cheek facial area, particularly when the air is forced such as blowing one’s nose. A cheek implant may be laying right next to or even over the original osteotomy line. This air being forced into and around a cheek implant (if it is not secured with a screw) make make it move slightly from the air pressure. Air into the subcutaneous tissues of the face is known as crepitus, which you more commonly call ‘bubbles’.

Thus there is a bony hole right next to the cheek implant as the culprit of all of these symptoms. This is a relatively easy problem to fix by covering the bone hole (sealing the sinus from the face) and stabilizing the implant to the bone with a screw. This is a simple outpatient procedure done under general anesthesia with minimal recovery. The only question is what to use to seal the bone hole as a variety of materials can be used to accomplish that end.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have the adam’s apple reduction procedure. I am a natural man and I don’t like the size of my adam’s apple. It is very big but I have doubts whether I should do or not do the surgery. I have researched photos of men who have this surgery but I found a few pictures and a few angles but some of the results didn’t seem good. What has been your experience with adam’s apple reduction surgery and how good are the results?

A: I have performed many adam’s apple reductions and about half of them are for men who just have a very prominent thyroid cartilage that is more than just a neck bump. The amount of visible reduction, however,  can be variable based on the anatomy of the thyroid cartilage, the thickness of the tissues overlying it and the aggressiveness and experience of the surgeon doing it. I suspect for most men who just want less of a neck bump size, rather than a completely flat neck profile, that the results are very satisfactory. It certainly can be difficult in some patients to get complete elimination of it but that it is not usually the goal of men looking to make a big adam’s apple prominence smaller.  I would suggest that you send me some pictures of your neck, particularly from the side, for my assessment to see if this procedure would be worthwhile for you in terms of the amount of reduction that could be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering labial reduction surgery with a tummy tuck. It seems like a good time to do both since they are in proximity to each other and I assume that the bigger recovery comes from the tummy tuck anyway. My plastic surgeon was fairly thorough on the after surgery instructions for the tummy tuck but told me nothing about what to do after the labial reduction. What do you tell patients after this kind of plastic surgery?

A: While the size of the area operated on in labiaplasty is relatively small, it is in a sensitive area. Good hygiene with sitz baths or a spray bottle several times a day is needed and the application of antibiotic ointment for a week after surgery. Since you are having a tummy tuck, cleansing the area with a spray bottle will need to be done. Oral antibiotics are given and will be taken for a week after surgery. If you have a known problem of developing yeast infections while on antibiotics, Diflucan will be given along with the antibiotic. Narcotic pain medication will be needed for the tummy tuck so this will cover the labiaplasty as well. Expect some swelling and a little bruising of the labia for a =few weeks afterwards. Cool compresses can be used to help alleviate pain and help with the swelling. From an activity standpoint, moderate exercise can be resumed after three weeks. One should not have intercourse for a month after surgery to prevent irritation of the suture lines and possible wound opening. Other activities that require straddling a seat such as horseback riding and bicycle/motorcycle riding should be similarly avoided.  For the same reason, tampon use should be avoided for a month as well. Be aware that scar tissue will form along the suture lines and this will initially feel hard and sometimes a little sensitive. This will take several months to soften. By six weeks after surgery you should be able to return to all activities without restriction and be fully healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just got stitches above my top lip. The stitches go across the ridges under my nose. I’m so worried it’s going to leave a ugly scar. My dog jumped on the couch and his hind foot landed on my face. He felt like he was losing his balance and used his claws and that is how I got the cut in my face. The ER doctor did a good job on stitching up the cut. The cut goes from my lip to my nose. What can be done to keep the scarring down?

A: What you want to do to get the best lip scar result is the following. First, get the lip sutures removed in no more than 5 to 7 days after surgery. I don’t know if the doctor used  a layered closure or what size the skin sutures are. If there is no dermal buried sutures below the skin sutures, then have a glue dressing (e.g., Dermabond, Indermil) applied once the sutures are removed. Second, beginning three weeks after surgery begin to apply a topical scar treatment twice a day. There are many type of scar gels and strips but on the lip a scar gel is far more practical. Continue twice a day scar gel application until three months after the injury. At three months after injury it is time to evaluate the scar. If it is quite narrow and flat and the redness is fading fast then I would only consider scar gel for another month. If the scar is fairly narrow and flat but still very red, then I would do BBL (broad band light) therapy to work out some of the redness sooner. If the scar is irregular in contour or slightly wide then I would have some fractional laser resurfacing done to even it out. Only if the scar edges are widely separated and irregular would actual surgical scar revision be necessary. Expect the final scar result to take a full 9 to 12 months until the final and best scar outcome is seen.

Dr. Barry Eppley

Indianapolis, Indiana