Your Questions

Q: Dr. Eppley, I’m 4 months out from having upper and lower jaw surgery. A 2.5mm upper advancement with a 4mm transverse expansion and 3mm posterior impaction to correct an anterior open bite, along with a 3.5mm lower advancement through a BSSO. In addition to this, I had a 7mm chin augmentation through sliding genioplasty. While everything else went perfectly well, unfortunately the genioplasty ended up asymmetrical.

I’ve attached both frontal and profile pictures for you here, as well as frontal and profile pictures from before the surgery. In addition, my latest panoramic x-ray is included as well. I’ve also included a picture of my sulcus as it was before surgery, and as it currently looks now, as well as a “relaxed lip” picture as I believe I show more lower incisors at rest than I used to. Forgive the photo quality…interestingly, I look much worse in photos than in 3-dimensions. I’ve never been terribly photogenic. In addition, I have a bit of residual swelling in my upper center face.

In any case, obviously, I’d like to have the asymmetry corrected (I think its very obvious). So, I have these questions:

1) How difficult is it to correct? My OMS seemed to be very reluctant to do a correction and implied it could be very difficult which is why I’m looking to you for correction based on several recommendations I’ve received about your work. Do you think I be better off with fillers or pre-jowl implants to mask the asymmetry rather than redoing the osteotomy? There are also those pesky “dents” on either side of my chin (pre-jowl)…

2) Is there a risk of more lower lip drop–greater than the first surgery? I did notice my lower lip dropped a little bit…perhaps 1-3mm though I can’t be completely sure as I never really looked at it before and don’t have any previous pictures of my lips in repose. It’s obviously not a devastating lip drop/incompetence issue as I’ve heard about. Do you see anything with the sulcus that looks abnormal in any way? Would an additional surgery in this area be more risky in this respect? If there is a problem…can it be corrected?

I’m planning on coming up there in the next 4-6 weeks for an in-person consult, but wanted to get an initial opinion from you as to what you believe needs to be done. 

A: Thank for detailing your surgery and sending your pictures. Now that you are four months out from surgery, you can see largely see the effects of the surgery as all of the swelling has subsided and the tissues hav contracted back done to the bones. What I see is the chin asymmetry and the very typical notching at the back end of the osteotomy sites which can occur from a sliding genioplasty based on how it is cut. (angle) Your lower lip position is hard for me to judge since how you are now is all I know. But I will assyme that there is a slight lower lip sag/ptosis.

In terms of improvement, two out of three issues are straightforward. First, the jawline indents will need to be filled in which can be done with either a shaped mersilene mesh overlay implant or a wrap-around prejowl silicone implant. (1mm thick in the middle so it adds no further horizontal augmentation) Second, since an intraoral approach would be redone the mentallis muscle would just be repositioned and resuspended not only as a prevention of any further sag but may actually improve where your lower lip is now. Lastly, the bony chin asymmetry can be delt with two ways, eitehr reposition the genioplasty or shave down the large or more prominent side. Since you may be getting an overlay implant anyway I would think burring the bone is far simpler. The only reason to reposition the genioplasty is if there are other dimensions to it you want to change. I suspect what has happened is that with the typical central plate fixation used, one side got rotated a bit (no lateral stabilization) and the asymmetry resulted. The genioplasty can be recut and repositioned without a problem (never confuse can with want to) but you just should have a godo reason to do so and to make sure that something simpler may not work just as effectively.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face makes me look like I  am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. Thank you for your help!

A: To treat the soft tissue facial triangle area (lines drawn between the cheek, chin and jaw angles), the procedures of buccal lipectomies and perioral mound liposuction may be useful for ‘facial derounding’.  It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. A buccal lipectomy removes a very distinct large ball of fat that sits right below the cheek bone. It is done from a small incision inside the mouth. It is important to not totally remove it so one does not get a gaunt look later in life. But for someone with a really round ‘fat’ face this potential issue may be irrelevant. The perioral liposuction procedure removes fat from below the buccal fat pad that sits right under the skin opposite the mouth. It is done from a small incision inside the mouth. Done together these two distinctly different facial fat removal procedures can help create a facial thinning effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having a direct neck lift and was wondering if i would be a good candidate for the procedure. Also, I was born with a cleft lip. I would like to fill in the hairs on my upper lip to cover the scars. Could you use the redundant neck skin as a source for the donor hairs, since they are facial like the lip or would you use scalp hairs? Thanks.

A: Whether one is a good candidate for a direct necklift is based on the degree of loose neck skin, age and one’s tolerance for a very fine vertical neck scar. The direct necklift tends to be a procedure most commonly done and accepted in men older than age 65…although that does preclude any man younger than that age if they meet all the other qualifications. You are absolutely correct in  making the assumption that the neck skin could be the source of donor hairs for transplanting into the cleft lip scar.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had the Mandibular Matrix system implanted in 2010 including the two 7cm jaw implants and a 7cm chin implant. However after three years, the two jaw implants have shrunken/settled into my bone so that my jaw corners are around the same size as they were before the surgery. I plan to have my jaw revised. From looking around, I can tell that you are one of the top-experts on male jaw enhancement. Do you recommend replacing the jaw implants or stacking a new implant on top? What are the risks of bone settling and how can I reduce them. Also, how can I schedule a consultation and surgery date? I can send you pictures. Thanks.

A: My first question is whether the jaw implants have really sunken into the bone. That would be very unlikely given how the Medpor material is treated by the underlying bone. The first thing I would do is have a 3D CT scan done and a model made to really look at the current relationship of your existing implants and the jaw bone. It would be impossible to give good advice/recommendations without knowing the answer to this very important question. It may also be likely that any new implants may have to be custom made whether they would be placed on top of or in replacement of your existing implants. Be aware that it would be very difficult to remove your existing implants…not impossible but very difficult.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering how much of an advancement in millimeters via either an implant or genioplasty to achieve a more masculine chin and does my deep groove effect the outcome. Thanks.

A: How much chin advancement any patient can obtain depends on their anatomy. For a sliding genioplasty it is usually up to 12mms based on the front to back distance of the thickness of the chin bone. An implant can do more as it is based on how the implantg is fabricated, how much the soft tissue can stretch and the placement of the submental incision to place it. Increases in horizontal projections with chin implants can be done up to 15 to 18mms. In some cases, a coimbination of a sliding geniplasty with an implant overlay can be done with increases up to 20mms.

Any amount of chin advancement, no matter how it will done, does not change the labiomental sulcus and, in cases of significant advancement, will make it deeper. In a genioplasty the ‘step’ in the bone can be filled in to help preventing worsening the depth of the sulcus. In chin implants, the best simultaneous treatment would be fat injections placed directly beneath the sulcus.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had some type of chin reduction procedure 10 years ago (maybe burring down the bone?) but my neck and chin actually looks worse afterwards. I have attached some x-rays which show a single butterfly-type device with four screws, visible more so from the profile shots. Do you think the irregular bone shape underneath is contributing to any of this fullness? Or does this not matter? The wedge on the end looks like it is positioned a little high to me. Would something like F in the image below be a better option? I want my labiomental fold effaced more like the after-shot in F. Or could this also be achieved with bone burring? What are you thoughts about all this? I want to get rid of the bulbous shape and having small, short teeth doesn’t help matters out much.

A: Thank you for sending the x-rays. What they demonstrate is that you had a reverse sliding genioplasty for your chin reduction, not just a simple burring of the bone. (like image F in the genioplasty illustrations) That is why there is a 4-hole metal fixation plate and screws. This also explains, as I suspected, the submental fullness that developed and never changed after the procedure.

Repeating the original reverse genioplasty is only going to make your neck/submental area worse…and will not reduce the depth of the labiomental fold. Do not let that illustration fool you, it does not work that way in real life on the effects of the soft tissue above the chin bone. (anything can happen on a drawing)

I do think that the bottom of the chin bone needs to be reshaped (narrowed and reduced in height) but, again, that is not going to change the depth of the labiomental fold. Fat injection grafting is the best procedure to try and make that happen.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had chin reduction done when I was 13 (intraoral approach), however, there are still problems with it and it never has looked exactly right.  I think it may be soft tissue issues?  It still has a bulbous shape, and ever since the surgery, has this odd-looking submental fullness.  The underneath side of my chin sags and looks very unnatural and strange from the side; it has looked like this every since I had the surgery.  I don’t understand why this is…. is this fat or muscle or why doesn’t it look exactly right?  

Also, my bottom lip positioning is incorrect.  My bottom lip needs to come down and out (more everted), because when i smile my bottom lip goes in over my bottom teeth.  What I am wanting is a more normal-looking profile, less of a labiomental fold with a bottom lip that everts (instead of inverts) like normal, and a more sculpted chin (less fleshy and bulbous on the end and a more smooth profile without all the submental fullness.  

I talked to you before about soft tissue reduction of the chin, but I now have x-rays which might be more helpful.  I have attached my digital pics and the x-rays of my mandible (DICOM files).  Would only a soft tissue reduction/augmentation be able to address my problems?  Or do you think I need something done to the bone?  Another ostectomy or bone burring?  I want to get rid of this fullness underneath and get a more sculpted, normal-looking chin, instead of a bulbous one.  What type of procedure or procedures do I need to fix these problems and improve my profile? Thank you 🙂

A: Good to hear from you and I remember your case quite well. Let me dissect all your issues one by one. First the submental fullness is a soft tissue isseu of too much fat and loose skin, which often  happens from an intraoral approach to horizontal chin reduction particulalry if done by an osteotomy. Just that alone could be corrected by a submentoplasty procedure to flatten out the submental fullness and tuck the tissues under the chin. Secondly, the files of the x-rays you sent me were text and not the images and I have no way of opening them in an imaged format. You will have to send me the x-rays  actual jpeg files. But even without the x-rays I believe you need further chin bone reduction/reshaping to have a more sculpted chin shape. The value of the x-rays for me is to know whether there is any hardware in there and what the bone shape looks like. Thirdly, no chin procedure is going to change the depth of the labiomental fold. That has to be addressed directly by either fat injections or a subcutaneous implant to soften its depth. Lastly, the lip position and how it moves is not something that can be reliably changed by surgery. The only option is to do a v-y internal mucosal advancement to create more eversion but this will not in the long-run move the lip position lower.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I was thinking about have a nose job, I’ve been thinking about this for a long time! But i’ve made myself really paranoid buy looking at the bad points, but i am so insecure about my nose! I don’t know what to do? 

A: The first place to start is to list what you do not like about your nose and what you would change if you could. Secondly it would then be important to see what is possible by rhinoplasty surgery by having some computer imaging done of realistic surgical outcomes. Then you can see if rhinoplasty surgery is worth the effort. If you send me some pictures and the changes you would like to see I can do that for you. This will give you good information to decide about what to do with your nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you perform Love Band eyelid surgery. I have lost the fat padding directly underneath my eyes, which I would like back. In Korea, they call these fat pads “love bands” and promote surgery to enhance that area via fat transfer in order to make the eyes appear bigger. Do you offer “love band surgery” as welland not just fat grafting for lower eyelid hollows? Thanks so much.

A: Love Band surgery is fat injection grafting done just under the lashline of the lower eyelids to create an elevated skin roll. This is done by placing small fat droplets in a linear fashion with a microcannula technique. It usually takes less than 1cc per eyelid to create the roll. This is viewed in some countries, particularly Korea, as enhancing the eye area and making it more attractive. It is a variation of contemporary fat injection grafting that is done just to one specific area of the lower eyelid in a very precise manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.

A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw/chin implant 14 weeks ago, it was two separate pieces that were screwed in. I would assume most of my swelling is gone but I have asymmetry as one side is lower….my Dr. is a reputable surgeon and is working with me, we meet approx every 5 weeks or so….he said if necessary he can go in to the one side, make a small incision and file it down some (not remove it)…he also put some filler in the area right where the implant starts at the jaw so you can see it….said there is permanent filler we can use down the road….I guess my question is how does this sound to you…..is filing down of an implant an option when there is tweeking to do?? I greatly appreciate your help….also is filler routinely used to help “fill in” near and around an implant for a more natural appearance and do you advise that. Thank you for your time!

A: Let me make sure I understand exactly what implant you have. Using the term jaw/chin implant could be either an isolated chin implant or a combination chin and jaw angle implants. I suspect you mean a chin implant because it is two-pieces which would also make it a Medpor two-piece chin implant. If there is asymmetry between the two positions of the two pieces  and you are certain that it is not just swelling (more than 3 months after surgery), the best approach is to go in, unscrew the implant, reposition it higher and screw it back into place. There is nothing wrong with cutting down the lower side but that can be harder than it seems to do smoothly and evenly with the implant in place. As a general rule it is always better to fix the primary problem (implant) rather than investing in camouflaging the problem by injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My goals are increased horizontal projection of my chin( no vertical lengthening)and a more square chin. Jaw angles flared out with augmentation of the angle itself and of the ramus but not the body? ( not necessarily a drop down of the angle itself as I think the angle is low enough currently). Rhinoplasty to decrease the hump in the nose possibly decreasing the width of the bony part of the nose when viewed from the front and the tip refined somewhat( picture with red hat)( My morph( lateral view of my nose in the blue shirt) I admittedly got a bit crazy/unrealistic with the tip of the nose. Finally, liposuction below the lower jaw/chin area to get rid of the adipose tissue that has always been there no matter my weight( a good 10-15 mm in various spots under the jaw/chin when I do a pinch test.) Also, wondering if the chin implant can be placed through an existing scar on my chin from my childhood.( picture added of scar 20 mm long and 10 mm long in the 2nd aspect and around 3 mm of width to the actual scar line( the scar is basically a T shape) Attached are some before and after pictures that I’ve done in photoshop as what I’m kind of looking for in general terms. I don’t know if this is even possible / what would be proportional for my face, but thought I would include them as a rough reference since I’m not there in person currently. My overall goals are increased balance in my face as I think the upper 1/3 of my face/ head is much larger then the lower 1/3. Also, I’m looking to do this with IV/ twilight sedation and not general. I’ve had septoplasty (2004) and a hernia operation in the past with just iv sedation(+ spinal for the hernia sx) and prefer this option. Thanks a lot.

A: Thank you for sending your pictures and doing the array of imaging. My review of the imaging matches fairly well with your goal descriptions and I would agree with much of it with the exception of a few minor variations.

For your chin you seek more horizontal projection, a more square shape in the frontal view and no change in its vertical length That would be possible using a square silicone chin implant, probably of at least 7mm to 9mms in thickness placed through a submental incision. It would not be wise to use your existing scar as it is too small, would become more prominent as the chin is pushed forward and would dive through the mentalis muscle in the process. A scar revision can be done on it but it would not be used to place the implant.

Your jaw angles show width expansion, a sharpening of the angles and no vertical lengthening. That could be accomplised by a 9mms silicone lateral augmentation implant placed directly over the existing angles.

The only comments about potential results with these implants is that the angularity of them (point of the angles and sharpness of the chin corner) may or may not be as sharp/pronounced as you have shown. The other issue is the continuity or smoothness of the jawline from the chin back to the angle. While the ends of a square chin and jaw angle implants will overlap, these overlapping areas are not as thick as the other parts of the implants. This it is not clear that the jawline will be as perfectly smooth from front to back as you have imaged.

The nose can be changed through an open rhinoplasty with a hump reduction and tip narrowing and some mild lift. I think those results are very achieveable.

Lastly, this collection of combined facial structura procedures can be done very well under just IV sedation. These are operations that are best performed under general anesthetic to get the best result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had an operation on my forehead almost 16 years ago that changed my life. My frontal sinus was backed up causing me to have had my forehead bone removed and replaced with my hip bone in fear that it was infected. I have a cut along my hair line but my forehead does not look the way I wish. How much does a reconstruction cost to have some material to over lay the bone for a more normal look? Thanks!

A: I am assuming based on your description that you originally had a frontal sinus obliteration procedure in which the sinus lining was removed and filled in with an iliac marrow graft. This undoubtably healed in a very irregular fashion, leaving the brow bone area with an uneven contour that may even be a bit sunken in. The brow bone/forehead contour can be significantly improved by an onlay frontal cranioplasty using hydroxyapatite cement. That can be done using your existing hairline scar. In order to properly estimate costs, please send me a picture of your forehead for my assessment so I can see how much cement may be needed which can highly influence costs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have had surgery for migranes the first one was 2012 all four trigger points and deviated septum. about 4 months later I developed a very suttle yet painfull pressure pain in my right temple. It was relentless. feb 2013 the surgeon went back in and removed an artery. for a week I was sure it was better then it came back again. since then I have had steroid injection and anestetic injected in the temple.. no help then botox injected.for two days after I felt great accually thought I might have a life. then the pain came back and remains and it sometimes triggers a full blown migrane, yesterday I got a shot for a migrane I was given demerol toradol and benadryl and phenigan. It helped in all areas but not in the area in the temple I still had the pain.. I cant live like this. the surgeron removed a portion of the zygomatic nerve.

A: Based on your description it sounds like you have had every migraine surgery approach for your right temporal migraines. The zygomaticotemporal nerve has been avulsed and the anterior branch of the temporal artery has been ligated/removed. Short of a temporalis fasciectomy, there are not other surgical options that I know. The fact that Botox had little to no sustained effect does not bode well that any further surgical manipulation would have a high chance of being effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get the upside frown surgery.  Can you please tell me how much this would cost?  How long would recovery take?  Is the surgery painful?  How long does it take to get an appointment?

A: Thank you for your inquiry. It appears that you have an ‘upside down froen’ issue. In looking at your pictures what i see in a level smile line but an overhang of the mouth corners turning into deep marionette lines. This is not a problem that will respond well to a more simple corner of mouth lift alone. While that will get rid of the overhang at the corners of the mouth it will not improve the deep marionette lines. That problem can be simultaneously treated with either fat injections or (ideally) a jowl line lift to pull back the tissues that are falling forward.

For the sake of providing some sort of a cost quote, let me for now assume it would be a combined corner of mouth lift with marionette line fat injections. I will have my assistant pass along the cost of that procedure to you later today. This is not a painful procedure with minimal recovery. (just some mild swelling) Surgery can be scheduled as soon as your schedule permits.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I can not seem to find any surgeon who performs shaving or burring of the jaw angles! They all do osteotomies of the angles and the results look awful and unnatural. Would you know why most facial feminization surgeons do not shave the jawline? They cut off the bone (angle resection) instead. I am wondering if it is a typical technique used by FFS surgeons? Because they operate men to become women so they go extreme. I am already a woman and just want a softer jaw. Would you know how many mm can be shaved off the angles? and how many mm off the jaw close to the chin? maybe it is so limited that they rather cut so they can remove 1 to 2 cms, which to me, seems a lot on a face. I wonder if I should go to a maxillofacial surgeon instead?

A: My best answer is that is just a lack of experience and knowing the different options that can be done. Also total jaw angle removal is easier to technically perform than outer cortical reduction with jaw angle preservation. It is important to apply the right operation to the patient rather than just the one operation you know to every patient. Most likely you can get about 5mms reduced from each jaw angle reduction, tapering to about 3mms behind the mental nerve.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a open rhinoplasty during June of 2012. My nose in the beginning looked great, but gradually it got a bit more but it went down gradually in time, though it is still swollen on the tip. But approximately two months ago I was washing my face and pressed on my nose and I heard a “click” and some blood came out. Since then I always get a bit of blood from my nose in my snot. I put vaseline inside my nose, which made the blood to stop coming, I guess it was dry on the inside. A month after the “click” in my nose, it became really swollen. Even though people don’t see a swollen nose, I know that my nose don’t look like this. Ive cleansed my nose with salt and water on the inside, I’ve used cortisone nasal spray, I’ve got antibiotics and cortisone tablets. The cortisone tablets really helped but only for a day or so, after that my nose went back being swollen. I do not know what to do, and would really appreciate your help.

A: I am going to assume that your open rhinoplasty was done using your own cartilage and no synthetic implants. In an open rhinoplasty a columellar strut graft is often used and this is really the only thing that can cause any clicking after a rhinoplasty if you move the nasal tip. But this is a natural material and not a source of infection or would cause an open areas inside the nose where the incisions where.  At 10 months after surgery you are rapidly approaching the time when you are reaching the final result although I would not pass final judgment until a year from surgery. You may consider doing some low dose kenalog injections in the nose to get some further nasal tip refinement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley,I was interested in getting a chemical peel or something for my skin type to help reduce/get rid of acne scars, melasma, freckles on my face.  I am half asian/white and I am concerned about scarring and hyperpigmentation from doing such a procedure.  I wanted to know your experience has been with asian patients and the success you have had with them.

A: I am not very enthusiastic about treating patients with intermediate skin pigments for discoloration issues because, as you know, those skin types are very problematic and often as many problems are created as are solved. Acne scars are problematic in any skin type in terms of the degree of improvement and the concept of completely getting rid of them is not usually possible. The fractional laser can help but, again, in intermediate skin types one has to balance the depth of treatment with the risks of hyperpigmentation. Scarring is not a concern in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to put something inside my upper lip,  a piece of jewelry I have. I also have big lips so this should work. What I’m using is a tiny Christian cross. I want to litterally implant it into my lip through the pink part of the lip, meaning you would not see it at all as it would be inside my upper lip. Could you do that or would having a piece of metal jewelry inside my lip cause an infection like tetanus?

A: A small metal implant can be implanted inside the lip as long as it is not too big and is placed in a sterile fashion. This also means that the implant must be sterilized before its surgical implantation as well. There is always the lifelong risk of infection or extrusion as long as the lip implant is in place although it is impossible to predict exactly how significant that risk is. That would be based on how deep or superficial it is placed and what the metal composition of the implant is.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, two weeks ago I got silicone malar cheek implants done. At first the healing process seemed to be going fine but then I started to feel pain and discomfort in the area where my implant was at on the left side. My dissolvable stitches also broke so I was bleeding a lot and went back to the Dr. .He said the cut was half healed half open and from what he could see it looked raw and red looking, I was also having some fluid coming out. Obviously he said it was infected but said it wasn’t enough to concern him and put me on Amox/K Clav 875 for 2 weeks. It’s been 4 days & it doesn’t seem like it’s getting worse or better what do you recommend is the next step. It still hurts when I smile or chew and is more swollen then the other side. Could there be a pus pocket like an abscess in the location of the implant? How can I find out? I’m thinking maybe an x-ray or MRI can show if there is something forming around the implant causing the discomfort? If so can it be drained? I just don’t want to have my implant taken out if there is some other way to go. Thanks in advance.

A: The most typical postoperative time period for an infection to occur from facial implants is 10 to 21 days after surgery…so you are right in that time period. But whether you have an actual infection or not is not clear. It is either an infection or a wound dehiscence (incision separation), both of which can give you pain on mouth movement. There is no value in getting an x-ray or other radiographic assessment as that is not going to change the clinical management of your cheek implant problem. You have two approaches to do. One is to stay on the antibiotics, see how the intraoral wound heals, and let time dictate what will happen. If improvement is going to occur it will be slow and will not occur in just 4 days. If it is an infection, it will eventually get worse and be obvious. (antibiotics alone will rarely cure an implant infection) This is the most convenient approach (not surgery)O even though it is not the most efficient. The other approach is to go back to surgery, wash out the implant site and thoroughly clean the implant, re-insert it and get a good wound closure. This is not convenient (as it is surgery) but it is the most efficient approach and the most assured one to retain the cheek implant long-term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about the fat grafting procedure to correct the tear trough. I’m 20 years old and have had hollowness under my eyes causing dark circles for my whole life. The skin under my eyes is pretty thin, so all around my eyes looks purple, and there is a depression under my eyes causing shadow. This is exaggerated by my pale skin. I’m strongly considering fat injection for a more long term solution. I’m wondering how much of a risk I would have of developing lumps or cysts or scarring if I get this procedure. Are you very skilled at this procedure? How many of your  patients return with complaints about lumps, cysts, etc after getting the surgery? Are most of the side effects I’ve read about on the internet the result of less advanced techniques that are used?

A: Fat injection grafting in into the tear trough and lower eyelids is a common facial augmentation procedure. No matter what technique that is used for fat injections, there is always the risk of developing some unevenness or small lumps. Usually these are relatively minor and not a long-term problem. The key is to placed the fat deep along the infraorbital bony rim and not superficial under thin eyelid skin. The formation of cysts or scarring are not complications that I have ever seen with fat injection anywhere on the face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Where do you do surgery? What are the facility fees? What would the price be to narrow or burr the chin just at the bottom edges to make it look less square? Also, I have a flat forehead in the center with prominent eyebrow muscle, which makes the flat forehead area look flatter. How wold you fill in the flat forehead or the center of the forehead in a female? Fat injections? What would the price be?
And can you shorten the forehead skull if the hairline is a little high?

A: In answer to your questions:

1) My cosmetic surgeries are done in a private outpatient cosmetic surgery center. The operating room and anesthesia fees are based on the time that it takes to perform the procedure(s). That must be determined on an individual patient and the specific procedures they are having.

2) Narrowing the chin is done by intraoral ostectomies or removing the sides of the chin through a reciprocating saw technique.

3) A flat glabellar area can be built up by a variety of techniques with fat injections being the simplest to perform.

4) If one’s frontal hairline is too high, its length is not going to be lowered by reducing the height of the skull as that amount of skull height reduction can not be done. Shortening the long forehead is done by a procedure known as scalp or frontal hairline advancement.

I will need to first review some pictures of your face to see exactly what needs to be done before the costs of the procedures can be provided.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am considering liposuction again after having it 15 years ago on my abdomen. I am now 61 years old, 5’5″, 138 pounds and in good health. I’ve developed a spare tire around my middle since menopause. Do women my age have a good outcome with liposuction? I had some dimpling with my prior experience although I was delighted with the results. Also, should my doctor use a particular size cannula? I have also considered a tummy tuck but don’t want that much down time.

A: The contour results of liposuction at any age are based on a variety of factors including the quality (elasticity) of the skin and how the fat is removed which definitely includes cannula size and type. In today’s numerous liposuction methods, however, there is so much more involved than just cannula size that determines the amount of fat removed and the resultant smoothness of the overlying skin. A variety of liposuction technologies now exist based on different energies (ultrasonic, laser, high pressure water, power-assisted etc) as well as techniques to use them. How your liposuction is going to be performed and why should be discussed with your plastic surgeon. All of this aside, the risks of skin irregularities always exists with any liposuction method and given your prior liposuction experience it is always important to remember….past history predicts future behavior. If you have had skin dimpling before you will likely end up with it again.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Are malar cheek implants considered soft tissue augmentation? Are porous implants mainly used for submalar or malar cheek implants? Do malar cheek implants sag with time if not screwed in? Sorry if I am asking so many questions! Thanks!

A: Malar or cheek implants are onlay bone implants that create overlying soft tissue augmentation by pushing from beneath it. Porous or Medpor implants are one type of facial implant (silicone being the other) that can be used for facial augmentation. The material has certain advantages and disadvantage compared to silicone, which neither makes it better or worse than silicone in overall implant characteristics. Malar implants may shift or move from their original implanted position over time if not secured into position by screw fixation. (I would not call that sag but implant displacement)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have visited your website and am aware you do skull reshaping surgery. I was wondering if you could review the attached picture and can you notify me on what could be done for a skull bulge on one side that is just above my right ear.

A: The bulge to which you have shown is the temporal area which is composed of more muscle than bone. That can be very effectively reduced through a small vertical temporal incision, shortening the thickness of the muscle and reducing the bone a bit. I have done that type of skull reduction successfully numerous times. It is a short one hour procedure done under anesthesia. There is very minimal pain afterwards, no real recovery other than a little bit of swelling after surgery, and no physical restrictions afterward. It does result in a very fine vertical scalp scar measuring about 3.5 cms in the hairline.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, do you perform rib removal/resection surgery? Perhaps shaving down of ribs? I have one side of my lower chest that juts out too far and it is definitely from the ribs. I have attached some pictures so you can see what I mean. I hope to hear from you soon.

A: Thank you for your inquiry. Yes I routinuely perform rib grafting harvesting for rhinoplasty as well as occasionally done rib resection/shaving for chest contouring. It appears from the pictures is that your left subcostal area( ribs 6 through 9) protrude compared to the more normally-shaped right side. For left subcostal chest contouring, you need the cartilaginous portions of ribs 8 and 9 removed and ribs 6 and 7 shaved (beveled down) to get rid of the portion that sticks outs. This is done through a low subcostal incision of about 4 cms.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Specifically I have had a problem with “marionette lines” since my early thirties, I am now 41. I had Juvaderm twice about five years ago and I had Restylane this past October. I definitely prefer the Juvaderm and I was going to do that again. Maybe with some Botox as well because I also have smokers lines around my lips. I am not a smoker but I have a habit of constantly chewing on the sides of my mouth and that, along with genetics, appears to be a big contributor. I have not actually tried any Botox yet but research indicates the two treatments together could get me a nice result.

The reason I am inquiring about the Thermage is because my face is aging just like my mother’s, she had Thermage done in 2009 and had a great result. She has not had any follow up treatments and her face is looking very saggy again but I do think if she had kept up treatments she would be looking pretty good right now.

I am wanting to know which treatments would give the best long term results. The Thermage appeals to me more than injecting things into my face and it appears that it is something I could maybe do around once a year, where as the injections would need to be done more often. I am not opposed to injections and pain is not a factor. It is more about what is being injected into my face.

I currently get microdermabrasion every two weeks and I use vitamin C and lots of sunscreen because I am very pale.

I have been doing research on line for years about procedures. Now that I have some background information on what seems like a million options, I need to know what would work best for me and still be in my comfort zone. I have a big fear of looking plastic and unnatural, but now my fear of looking older than I really am is becoming bigger.

A: Thank for clarifying your problems. While the options for your concerns may seem endless, they really are not. The reason it seems there are so many is that none of the non-surgical approaches have any lasting effect and the differences in the results many of them produce are negligible. Hence, many things exists when none of them really work that well…at least compared to surgery.

For marionette lines, injectable fillers are the only real effective non-surgical option as you already know. Botox is not going to help the marionette lines because that it is not a muscular/animation problem. Botox can be effective for helping reduce some vertical lines in the lips and may help turn up the corners of the mouth a bit but it is a deanimator not a filler.

The use of Thermage is for the treatment of jowls and for some mild facial skin tightening. While once state-of-the-art in its day, it has largely been surpassed by many other ‘tissue heating’ technologies such as Ulthera or Exilis. They all work the same even though the energies that cause their effects are different. (ultrasound vs radiofrequency) While they do some good facial effects for some patients, they don’t really make new collagen that is sustainable and thus their effects are short-term. It takes a lot of maintenance treatments to keep their effects and that can quickly surpass the effects of surgery which is much longer-lasting. Face and neck treatments like Exilis when combined with overlay treatments of light fractional laser  resurfacing skin treatments is a very fine combination that for the right patient can produce some really good effects.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to have my jaw angles lengthened but don’t want to use the Medpor material due to infection concerns and being hard to get out. I can’t find a silicone jaw angle implant that does anything more than wide one’s existing jaw angles. What should I do?

A: New silicone jaw angle implant designs are currently under design and manufacture with the Implantech company. I am very familiar with that development as I am the plastic surgeon behind their design.  These silicone jaw angle implants will provide vertical lengthening that most jaw angle implant patients need. I believe they will be available through the company as part of their catalog of offerings by the summer and certainly no later than the fall. They are available for my use now since I have access to these newer jaw angle implant styles through the development process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 38 years old and in good general health. However, I was born with very small testes. They seem to be normally functional. I had two children before my vasectomy. I have always been self-conscious about this and wanted to explore the possibility of silicone implants. Is that a procedure you would perform? Or is that something normally performed by a urologist?

A: Thank you for your inquiry. Testicular absence or small testicles can be cosmetically enhanced through the placement of testicular implants. This is done though a small incision on each side of the scrotum in a short 60 minute procedure for both sides. The only FDA-approved testicle implant in the U.S. is a saline-filled silicone elastomer shell implant available through the Coloplast company. (formerly Mentor) Other than the oval shape change, it is very much like a miniature breast implant. It comes in 5 different sizes based on dimensions and the volume of saline fill. It is a procedure that can be done by a plastic surgeon like myself or a urologist based on their experience with implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, this is a question regarding the lip line, particularly the tubercle area. I have an uneven “dip”; the left side has almost a cusp while the right side is much smoother. Other then that, I have full, almost Taylor Swift Lips (except for the left side unevenness), lips. Is there any particular recommendations to make both sides ~symmetrical, particularly the left which the problematic (visual) area? Thank you.

A: What you are referring to is a higher/sharper cupid’s bow on the left side. The goal then would be to lower the higher side to make it match the smoother and lower right side. That can be done through a small excision of the arc of the cupid’s bow done under local anesthesia, just like a miniature reverse lip lift.  That would be very effective at lower and ‘desharpening’ the higher cupid’s bow but at the price of a small price of a small scar along the vermilion-cutaneous  junction. Whether that would be a good trade-off would depend on the degree of upper lip asymmetry that you have.

Dr. Barry Eppley

Indianapolis, Indiana