Your Questions

Q: Dr. Eppley, I am a 28 year-old male, fairly thin, with concerns about my facial profile. I feel that I have both a weak chin and jawline and have some concerns with mandibular vertical height as well as width. Any advice would be greatly appreciated. I have attached some cell phone pictures for you to see what I look like.

A: I have taken a look at your photos and can offer the following comments.

1) I do agree that your chin does have some moderate horizontal deficiency as well as a touch of a vertical deficiency as well. (short vertical anterior height)

2) Your jaw angles show good vertical length (posterior vertical height) and no deficiency in that regard. I do agree that there is some width deficiency in the jaw angles however.

Taking these two pieces of information would indicate that the correct surgery would be lateral jaw angle implants and a square chin implant that is positioned as low on the inferior border of the chin as possible to gain a few millimeters of vertical height as well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have very small earlobes since they were repaired from my gauging last year. After the repair the earlobes were too small and it bothered me greatly. A local ENT doctor that I saw talked me into using tissues from behind the ear to make an earlobe but it looked terrible. So I had him reverse the operation which now left me with scars behind my ears…but there is nothing I can do about that now. Is there anything I can do now to help make my earlobes bigger?

A: I am going to assume that these two sets of pics I have seen represent an initial attempt at local flap reconstruction of the earlobe which was subsequently taken down because you did not like how it looked. So the most recent pictures are the healed ear wounds now. I would first do some injectable fillers to stretch out the scar and surrounding skin of the earlobe. The purpose of the injectable fillers is to act like a temporary form of tissue expansion. It may take more than one injection to see how much they can stretch out over the course of a year.  Once the earlobes have been stretched out (if they will), you may eventually place a small dermal-fat graft in them for permanent volume maintenance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is a breast lift without scars possible. I am 38 years old and am done having children. (3)  I have 36 D breasts but they have a lot of sag. I would like to lift them with implants. I want minimal scars and I have read that the implants can be inserted through small incisions in the armpits or areola that leave minimal scars. I don’t want any scar outside of the areolas. I am hoping that the implants can get me enough of a lift, maybe a bigger implant will get me more of a lift. What do you think?

A: Unfortunately the approach you are thinking about for lifting your sagging breasts is an understandably misunderstood one. No woman really wants breast lift scars but the reality is that there is no substitute for them. Basically without scars there will be no real lift. Breast implants can not lift a sagging breast and will actually make it worse if tried alone to lift a saggy one. Once the nipple hangs at or below the lower breast crease, adding implant volume will only drive the nipple even lower…and place a large amount of fullness (implant) above the nipple. Filling out deflated breast skin will only make a nicely shaped breast if the nipple already sits close to the center of the deflated breast mound.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 30 year old male who works out regularly.(6’4, 200lbs) I am looking to get fat from my lower abdomen removed so my 6-pack can show. Would you recommend Zeltiq or liposuction? Knowing that I am on a budget and prefer non-invasive procedure however still looking for best results.

A: The simple answer is that Zeltiq, or any other form of non-invasive fat treatment, has zero chance of removing enough fat to make a six-pack show. Liposuction with an etching technique is the only procedure that has any hope of making a six-pack look…provided you are lean enough to begin with for the etching results to show. Six-pack abdominal liposuction is only effective on reasonably lean patients. It can not create a sculpted definition on a thick abdominal wall.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I just turned 60. I had breast implants in 1985, thinking I need to have them removed and put in new ones. How much would that be? Also,wanting to find out about around my eyes, had botox but my skin is thin and I look tired all the time. Is there fillers? Had filler around laugh lines and below my eyes but didn’t work or last. I need help.

A: Thank you for your inquiry. I will assume that since your original breast implants were placed in 1985 that they were silicone and probably were placed above the muscle. The pertinent questions about them now 25 + years later is do they need a total capsulectomy (removal of all surrounding scar tissue), are the existing implants ruptured, and what type of implants (saline vs silicone) do you want to replace them. All of these factors control what needs to be done and the cost to do them. So any information that you can provide me in that regard would be helpful in deriving the cost of surgery.

When it comes to your face, you have already learned that injectable fillers are not going to provide any solution for tired looking eyes at your age. Most likely this is a surgical issue of removing excess skin and fat (blepharoplasty surgery) to really get a substantative change in your eye appearance. I can answer this question more definitively if you can send me some pictures of your eyes.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was interested in having liposuction in order to remove the perioral mounds in my face. I am 20 years old. I have some questions related to this operation. First of all what are the dangers of it and how much time does it require for the face to be full recovered? Will it damage my face muscles? Does this liposuction last? Will the fat mounds come back again? I was also curious to know if this operation is going to remove the marionette lines from my face.

A: In answer to your questions about perioral mound liposuction:

1) There are no dangers to the procedure, nothing adverse can happen to your face. It is just a question of how much reduction can be achieved.
2) It will take a full 3 month to see the final results of the soft tissue reduction although about 85% to 90% is evident by 6 weeks after surgery.
3) It will not damage the facial muscles.
4) Unless one gains a lot of weight, the results should be permanent. The perioral mounds are not a fat depot area. They are usually there due to congenital development not as excess fat deposits due to too many injected calories.
5) Perioral mound liposuction will NOT remove your marionette lines. They are not there because of the fat in this area.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had  some facial feminization procedures done not too long ago. I had a sliding genioplasty as one of them. I now have the often present notch on either side of the osteotomy. I expressed concerns about minimizing this with the original doctor. The depressions are fairly evident. Also my infra orbital area is lacking. This lacking does not help with a feminine appearance. Over all I am having trouble determining what needs adjusting on my face because the face is the sum of its parts. I need an opinion so I can decide what to do over the next 12 months. I hope to improve symmetry also. I have to wait at least six months to undergo any further work since surgery was not to long ago. I have attached some pictures which hopefully are helpful although they are just one week after surgery.

A: Based on these even very early pictures, your chin is now too vertically short for your face. You have a longer thinner face and now the lower third (chin height) is too short. That is what is throwing off your facial proportions. Also as part of a longer thinner face, the cheek/infraorbital area is flatter. Thus I would recommend a chin bone lengthening (opening back up the osteotomy), infraorbital rim implants, and a subnasal lip lift. This will bring your face into better proportion and balance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 6 weeks post surgery today from my chin reduction procedure. I am feeling great, most of the swelling is gone. I know I need another month or two for final result, but I pretty much can see an outcome. My chin looks so much nicer without  that point and loose skin. The straight cut that you’ve done suits my face a lot better. But if it was possible I would still want to go a little shorter (it didn’t go as short yet). Maybe it will shrink a little bit more, but I don’t think the change will be very drastic from this point on, as I can feel where the bone is. That is why I wanted to ask you whether further attempts could be done in the future.

1. Do you think there is room on the bone  for more reduction? Of course it is all in the case it won’t go down to where I want it. One side is slightly longer now, it doesn’t bother me at all, but maybe it can be raised if there is no room on the other side?

2. How risky is it to do it again?

3. When is it normally done, after healing is complete or before it? What are the time frames?

4. Non related question, how long do i need to wait before any dental work? Also,do I need to take more calcium or less?

Thank you very much. 

A: Thank you for the follow-up. In answer to your questions:

1) The way to determine if it is safe to do further chin bone reduction is to get a panorex x-ray. (standard dental film) That will show how much distance remains between the lower tooth roots and the bottom part of the bone. I suspect it is fine to do more but it would be important to know the actual distance left between the apices of the teeth and the bone.

2) see #1.

3) The timing of any further efforts is always on the ‘stable target’ premise. It can be done as soon as one is sure that what they are looking at as settled down and no further changes are going to occur…. and one has psychologically adapted to the change.  When it comes to facial bone work that is usually 3 months.

4) You can proceed with dental work at amy time. Taking calcium supplements won’t make any difference positive or negative.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost a testicle in my youth. I am 50 now and am tired of the embarrassment. My wife divorced me, said was tired of half of a man. Can you help?

A: Like many other body parts, implants are available for testicular replacement. An FDA-approved implant is available for testicular replacement/reconstruction and is a saline-filled implant, very much like a miniature saline breast implant. A testicular implant procedure is relatively routine and can last from 30 to 45 minutes, usually performed under  IV sedation or general anesthesia as an outpatient operation. It has a quick recovery with minimal discomfort although there will be some scrotal swelling. It is important to know that testicular implants, like other medical implant devices, should not be considered lifetime devices. There is the chance, though minimal, that the body could have an adverse reaction to the implant, or that the implant may either rupture or leak (or both). Such events would require the implant to be removed  Based on clinical studies of the saline-filled testicular implant, approximately 1 in 30 patients (3.3%) require resurgery within the first year to either remove or adjust the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had surgery in the beginning of December of last year for chin reduction surgery. I just had some basic questions for you that I will ask now. It’s been 2 months and the swelling has gone down quite a bit, I’m curious if there will be any more reduction or is this the extent of it. Also, I’m still feeling a lot of resistance in my chin area. Not numbness just resistance. Is this normal? Is this something that I’ll just have to get use to?

A: Good to hear from you. I generally feel that it takes up to a minimum of 3 months after surgery for maximal tissue settling and complete swelling reduction of any facial bone reduction surgery including the chin. So you are probably about 85% there now. Also the chin stiffness will eventually go away I believe but that will take much longer, perhaps as long as 6 months or even longer. The normal feeling/movement of the chin may even take up to a year for complete softening of the chin tissues.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to achieve a more masculine jaw line. My face is oval and I want a more square cut lower face. I had a chin implant back in 1990 with a rhinoplasty. Would like to know what my options are and also would this implants just be inserted or are they secured with screws. How many days do I have to stay inIndianapolis before flying back to home. Thanks so much for your fast response.

A: Thank you for sending your pictures. I did some preliminary imaging based on what I perceive as your desire for a more masculine jawline. This was done using a combination of chin and jaw angle implants, the most common approach to make a circumferential change to the jawline. One interesting issue with you is that you already have a chin implant and the change to get you to the imaging result is significant. This raises the question of whether an off-the-shelf (stock) chin implant can really achieve that goal of which I have doubt. This leaves the possibility of either making a custom chin implant or doing a combined sliding genioplasty with a small square chin implant placed in front of it for the square width effect.
All facial implants are always secured by screws for stability of position on the desired bone position long-term.
No matter how it is done, you would be returning home 48 hours after surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in forehead augmentation to improve my sloping forehead above my eyebrows. I can see how that would improve the shape of my forehead in the profile view but I am curious what will happen in the frontal view. I have attached a front picture of me and marked with arrows the area of my forehead that I see as too narrow.

A: You bring up a very critical point in your forehead concerns. The area to which you have shown the areas is not the bony forehead. That is the soft tissue temple area. That would be unaffected by a bony forehead augmentation and may well look somewhat more narrow as the bony forehead comes forward. (probably won’t change it very much if at all) To improve temporal fullness or width, that requires a temporal shell implant placed on top of the muscle to build up that area. (make it wider) It is common to not be aware that the width of the bony forehead stops at the anterior temporal line that runs above the corner of the eye back into the scalp. This is where building up the bony forehead stops. Beyond that line to the sides the contour is controlled by the temporalis muscle and deep fat pad.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Not sure what I really need. My forehead has deep wrinkles, I have sagging eyelids, bags under my eyes and jaw line and under chin drooping. Is this a full facelift or what?

A: What you are describing are numerous facial aging changes that are located around the two main areas that bother people the most, the eye area and the jawline/neck region. Unless there is some significant eyebrow sagging, the forehead wrinkles are treated with Botox injections and not surgery. Changing these two aging facial areas require a combination of blepharoplasties (eyelid lifts/tucks) and a neck-jowl lift. This is often interpreted as a ‘full’ facelift but this is not really an accurate description. A facelift is the purest sense of the word really just addresses the neck and jowl area and nothing above the lower 1/3 of the face. You may have interpreted eyelift surgery as part of a ‘facelift’ but they really are a separated procedure that is often done simultaneously for a more complete facial rejuvenation effect.

Please send me some pictures of your face for my assessment and a more individualized answer for your needs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hi, I’m a female with a fairly prominent brow and small, receding forehead I’d like to improve. My face as a whole is convex rather than flat: Can the areas outside my eyes be “filled?” How would forehead augmentation affect deep wrinkles? Thank you!

A: Thank you for sending the edited picture. What I see is a mildly recessed forehead and a very recessed chin. The combination of the two is why your facial profile is convex. I have done some imaging for a forehead augmentation (not brow) and a chin osteotomy or sliding genioplasty. Your chin is too short for an implant and it also needs some vertical lengthening as well as bringing it horizontally forward. Also forehead augmentation usually will soften deep horizontal wrinkles as the skin is stretched out by the underlying material expansion.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am bothered by the hollowing under my eyes. I am scared of injectable fillers placed so close to the eye . I’m thinking about the surgical procedure using implants. Have you done it ?  How good are the results ? This hollowing thing really bothers me . It makes my pictures look bad. I don’t expect full correction, I’ll be happy with an improvement.

A: When you speak of implants for hollowing, you are referring to infraorbital rim implants. I can speak to the success of the procedure having done it numerous times. Done through a lower eyelid procedure, it is done through a lower blepharoplasty incision and the implants are secured to the bone with small microscrews. It provides a permanent correction to the lower eyelid hollowing problem. The biggest problem with them is the risk of palpability (being able to feel them) and asymmetry of the upper implant edges.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had lap band 3 years ago and am looking to have excess skin removed, a breast lift and some liposuction in the arms and legs region, just wanting some prices and if my insurance would cover any of it due to being post lap band.
A: To answer your questions, the first thing I need to see is some pictures of what your body looks like. What I am particularly interested in seeing is the size of your abdominal pannus and the degree of breast sagging that you have. But in the interim, let me provide you with some reality about the bariatric surgery patient and and what insurance will or will not do wit the sagging skin that develops afterwards.
1) The only procedure that has any remote chance of being covered would be an abdominal panniculectomy, removal of the abdominal overhang or a simple amputation tummy tuck. But for this to even be considered, a pre-determination letter must be written that describes the medical symptoms the pannus is causing and pictures that show the amount of abdominal overhang. To qualify the pannus must hang over the groin creases and onto the upper thighs and there must be a documented history of treatment for intertrigo. (skin infections under the pannus) Based on this submitted information, it is up to the insurance company to make a decision about coverage.
2) Breast sagging and the breast lift with or without implants is not considered a medical necessary procedure and is not eligible for insurance coverage.
3) It would be extremely unusual for the extreme weight loss patients to benefit by liposuction. The skin quality is often too stretched out to respond well to fat removal alone.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am 34 years old and am 5’ 6” tall and 165 lbs. To my own credit I have lost 54 lbs over the past year with diet and exercise; It has been tough but I have done it and I am determined to lose even more. But I appear to have hit a point now that the weight is not budging. My problem is that I now have an apron of skin and fat that hangs over that has started causing a lot of discomfort during any form of exercise. I am doing all I can from a diet and exercise standpoint. Should I go ahead with tummy tuck surgery now or wait until I lose more weight?

A: Now that you have hit the proverbial wall and have an overhanging apron (pannus), I think you would benefit by a tummy tuck right now. The psychological benefits would be enormous and would empower you to lose the additional weight afterwards. I have seen this effect many times in patients who look just like you and have the identical story. Tummy tuck surgery itself will casue some additional weight loss by what is removed, which is usually in the range of 3 to 7 lbs. (everyone thinks the apron weighs a lot more than it actually does) But an identical if not more weight loss occurs from the recovery process. (burning calories to heal) This is why many tummy tuck patients like you will be down in weight 15 to 20 lbs by 6 to 8 weeks after surgery. That provides a good surge towards your eventual weight loss goal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had muscle reduction done for my very bulgy temporal areas six weeks ago. While there is already visible improvement, I do have some minor concerns and wanted to know if what I am experiencing is normal. I have noticed that the temporal area in the non-hair bearing portion above the cheek arch seems to be a llittle bigger than before. It is soft and fleshy and does not hurt. Will it stay this way or go down with some more time? Also my mouth opening seems to be lityle less wide than before. I have no problem eating and speaking but it does not seem to go as far open as before. Will this stay this way or will it eventually return to normal? Right now it measures 38mms between my front teeth when I open as wide as I can.

A: Seeing the final result after temporal muscle reduction is a process that takes up to six months after surgery to see the final contour result. So at six weeks you have a ways to go. But to address your two specific concerns:

1) That bulging just above the zygomatic arch is very typical at this point. The muscle has shortened so the bulk of it, for now, is in this area. This is where the muscle passes under the zygomatic arch and is it’s thickest part. Also it also may appear bigger (even if it is not really bigger) because what was above it has gotten smaller. So it may be a relative perception issue. Like above, I wait for the full six months to see how the muscle changes.

2) So-called normal oral range of opening is 45 to 55mms. for most people.  (I just  measured mine and it was 48mms) Anything over 30mms is very functional and would not cause issues with eating or speech. I don’t know what you were before surgery but i suspect maybe 10 to 12 mms more. I would g ahead and work on some daily stretching of it to see if you can get back up to 40mm plus. I suspect you will be able to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have saggy breasts and I was hoping to avoid a lift so I would’t have scarring. Is it possible with a bigger implant not placed under the muscle that this can be achieved? I did try on 600cc with a bra and a shirt over and decided I wanted bigger. I was thinking of 800cc. I know I’m not the Dr. and this is something you would know more about. So with some of these things I’ve mentioned. Could you tell me if this can be a possibility. Thank you so much for your time.

A: One of the great dilemmas in breast enhancement surgery is that of the sagging breast. It is a common misconception that an implant is going to lift a saggy breast. While that is true for the very smallest amount of breast sag, it will simply not work for what most women perceive as breast sagging. If an implant can not lift a breast, a bigger implant will not do so either. As a matter of fact, the bigger an implant is in breast sagging, the worse the result may appear afterwards if a lift is not done at the same time.

So in what cases will an implant help lift a breast? Check where the position of the nipple is. If the nipple is at or just below the lower breast fold, some form of a lift is going to be needed. The other way is to do the pencil test. If a pencil placed underneath the breast stays, then a breast lift will be needed as too much sag is present.

In reality, implants help re-expand a deflated breast but it will not really lift a sagging one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I recently (3 weeks ago) had a lip lift which I am very unhappy with. I have attached the before and after pictures. What I expected with the lip lift was to have more lips all through out the upper lip, not only in the middle where the cupid bow is (looks like a chipmunk). At the same time I wanted to reduce the length between the lips and the nose. I always had thin lips and always wanted more fuller lips , upper and lower lip with shorter distance between the lip and nose. With the lip lift , I thought the lip would of been less thin on top and would of done fat transfer to have some fullness afterward.

A:  Thank you for sending me your before and after photographs. There must have been a miscommunication before surgery because your lip lift did exactly what it is supposed to do and can do…lift up the central third of the upper lip. It can not change the whole upper lip vermilion as the skin is only removed from the central third at the nasal base. The only lip enhancement procedure that can change the entire lip vermilion is a lip advancement where skin is removed alone the vermilion-skin junction from one corner to the other. That is a tremendously effective procedure but does produce a very fine line scar along the vermilion-cutaneous. That is why a lip lift is usually chosen for men although there is nothing inherently wrong with a lip advancement for men either.

You actually have a good early lip lift result. But although the operation may have been done appropriately, it may not have been the right operation for you as it turns out.

Lip lifts are irreversible, meaning you can’t put back the subnasal skin that has been removed. Your options at this point are the following:

1) Give the lip lift a few months to settle and relax because they all stretch out often up to 25% or more over time. Then decide what to do.

2) Jump in early and do lateral upper lip vermilion advancements (leave the cupid’s bow  alone obviously) to make the lip vermilion more even and lifted across the lip. You can do fat injections at the same time but you may not need to do so with lip advancements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, thank you for doing the imaging on the predicted changes from chin and jaw angle implants. I am blown away that this can actually be done. This is well beyond my expectations. What size implants would you be using for my jawline enhancement?

A: Quite frankly more extreme changes than those can be done but I kept at the limit of what I see as reasonable and not excessive. (I have attached some results so you can see how extreme it can be made if one wants…although I don’t advise that on you). Your imaged look can be approximated by a combined square chin implant (style II square 9mms) and bilateral jaw angle implants (lateral augmentation style silicone 11mms or Medpor lateral augmentation of 7mm size). If the chin would benefit by vertically lengthening as well, I would do a chin osteotomy for lengthening 5mms and bring it forward 7mm with an overlay of a small square chin implant style II of 3mms.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am looking at building up the back of my head. In reading your blogs you say that you usually add about 60 grams of material. But I don’t know how that would look and whether that is enough. I went on with my experiments, but rather than water I used plasticine which conveniently has a density close to PMMA, to check the volume. I adapted it to the back of my head like an implant would be, and as you said the change is bigger than one would expect (I tried 60g and 80g). So if the trade-off for a bigger volume is ‘longer or more full coronal incision’, could you tell me what would be its size and location for 60g and 80g? (I’m not sure I’ve read around 10 centimeters for 60g on your blog) As a side question, how would you attach the implant to my skull?

A: That is a clever way to see how much volume 60 grams of cranioplasty material is. Remember that it will also look bigger than you think when placed under the scalp skin. To get this amount of material on the back of the skull, an incision of 14 to 16cms long is usually needed. Onlay cranioplasty materials are fixed to the skull by first applying small screws to the skull bone allowing them to set up about 3 or 4mms above the bone. When the material is then applied this gives it something to hang onto to like rebar used in concrete. While screw fixation may not be absolutely necessary for augmentative skull reshaping, I prefer it since it is simple to do and adds a bit of security for prevention of implant mobility.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had malar and para-nasal implants, also infra-orbital porex placed in 2006, and six months ago removed because the malar increased my gaunt look, provided only lateral projection, and started to show through my thin skin. The paranasal implants didn’t really do much for me in terms of anterior volume, since they were placed so low on my long face.  Also, right infra-orbital implant became infected during removal of the malar implant and was also removed. Now I’ve got the left one still in there and, without the malars, the edges are poking through and it’s too small for my face. I trust my original surgeon and he wasn’t the one who removed the malar implants for financial and geographic reasons. Although the malars were kind of cool and from some angles gave me an “actor” look butI don’t want to replace them alone.

But, I do want to explore all options. That said, his idea is: 1) larger medpor tear trough plus midface lift. I realize the right eye is drooping. I also think there is some scar tissue where the paranasal was on right side that makes that cheek droop more and look puffy.   I know that midface lift means basically 2-month initial recovery and can leave one funky-looking, and seems to not really last that long.  I was thinking of the blepharoplasty to reposition the eye, instead??? (less invasive??) I like the idea of tear trough improvement , now that I can compare left vs. right, I see that my face needs it.

The groove and shadows beneath eyes are my biggest complaint.   Because I realistically, with my long and gaunt face because of exercise, it would take a lot to fill it out.  So I think a compromise of concentrating on eye area is the best option at this point. But I don’t want to go thru that recovery time and cost of the midface lift if it is going to fall in a year and the tear trough won’t be big enough and will start poking through….2) another surgeon I have worked with in past suggested malar-submalar combo, goretex.  But is worried that any implant will just show through. I am also open to this, to give some structure to my flatness, lower healing time, lower cost. 3) This second surgeon prefers just to use injectables.  I won’t do fat transfer because I will burn it off and it’s a waste of money and time.  It would just leave the left infraorbital implant in and try to compensate on right and in lower cheeks with filler under eye. At this point, though, I would be looking at minimum $6000 in filler.  

I had noticed the medpor porex tear trough implant and that, based on the brochure, seems to be what I’m looking for in terms of volume.  But, I don’t think my present surgeon would go for something this big,and he had mentioned the Hoenig model. Again, anything anterior he is against in order to avoid hitting the nerve.

I’m not against the midface lift, but at this point would prefer to save any lifting for a mini-lift 5 years down the road, perhaps with submalar added….  with skin excision not just suspension, when I really need it. And for the massive recovery time.  But, I have seen some awesome B & A of tear trough shadow improvement.

I don’t know…????  I started on this porex implant road and maybe just have to continue in this direction.

A: In answer to your questions:

1) Don’t do a midface lift. This is a longer recovery than most patients realize and with your facial skeletal structure you are at an increased risk of creating lower eyelid ectropion or an unusual look. With your thin facial tissues, you are always going to be at risk of tear trough implant palpability, visibility or asymmetry. But I can get more enthused about tear trough implants in you though than a midface lift.

2)   A small thin malar shell implant for the cheeks is reasonable and far preferable to a midface lift. With your thin tissues there is not much room for error about implant size as it is easy to end up in you with a visible implant look as you have had in the past.

3) Injectable fillers or fat in your thin face will not only not work well but has a poor return on investment over time.

4) There should be no concern about ‘hitting’ the infraorbital nerve going over the edge of the infraorbital rim. The nerve is well below it. That appreciation is just a function of having placed implants there before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a nicer more natural-looking side profile. I saw a before and after picture of a hispanic lady you did and like the result. I’m considering the following surgeries – brow bone augmentation, forehead augmentation and nasal bridge augmentation (higher nose bridge) to go with the newly adjusted brow bone.

I have a few questions…

1) Have you done this procedure on Asians before? If yes, mind sending me some before and after pictures?

2) How often do you do brow bone surgeries? I’ve done some research online and it seem that you’re the only surgeon that specializes in this.

3) How much are the costs to have the above surgeries?

4) What are some of the side effects/worst case scenarios?

5) Would you say I have protrusive eyes? I feel like there’s still some fat/excessive skin after eyelid surgery and my brows are too close to my eyelid.

Would also like to hear your recommendations.

A: In answer to your questions:

1)      Augmenting the forehead and nose to improve the profile is most commonly done in the Asian patient in my experience. They make up nearly half of all forehead augmentation patients in my practice. Building up the forehead with PMMA is the typical approach due to the volume of material needed. The end goal is to have a rounder forehead that eliminates any backward slope and flat profile to it. While the material can extend down and build up the brow bones as well, it is not possible to extend the material onto the radix of the nose to build it up as well. It may reach the frontonasal junction but true radix augmentation must be done from below as that area is part of the nasal dorsum not the forehead.

2)      Brow bone and forehead augmentations are done by few plastic surgeons and those who do them almost universally have a craniofacial training/experience background as that is how you learn to do any type of skull reshaping surgery.

3)      I will have my assistant pass along the costs of forehead augmentation to you by separate e-mail tomorrow.

4)      The most common side effects are shape or contour issues. How smooth is the result? Are the edges over the temporal lines visible? Is the amount of augmentation enough? Contour irregularities are the main reason for any revisional surgery which has a risk of about 10% in my experience.

5)      In looking at your pictures, I assume you recently had ‘double eyelid’ surgery based on the scar location. I will also assume that they didn’t take ouy any upper eyelid fat which commonly needs to be done in the Asian eyelid. Also, brow bone augmentation may increase the distance between the brows and the upper eyelid lashline.

6)      Lastly, radix augmentation needs to be done through the nose and is often part of an overall dorsal augmentation in an Asian rhinoplasty. I know that you stated you recently had a rhinoplasty but I do not know what was done. Did they build up the dorsum and, if so, with what?

I have attached some imaging predictions based on brow/forehead augmentation and a nasal dorsal augmentation.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 55 years old and am interested in getting my saddle bags reduced that have bothered me my entire life. I am concerned, however, that I may end up with skin that is saggy afterwards given my age and the little bit of cellulite that already exists there. What do you think about using Liposonix instead?

A: When you use the term Liposonix you are referring to an energy-based form of assisted liposuction just like Smartlipo or Vaserlipo. All use different energies to loosen the fat before it is suctioned out such as ultrasonic or laser energies. These are all forms of liposuction that pose the same risk of skin irregularities that any other traditional form of liposuction does, because the support of the skin is deflated as the fat is removed and the quality of your skin is not improving. Of all these energy-based liposuction methods, Smartlipo may be best because the heat that it generates in the treatment process may have some mild skin tightening benefits.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am sending you photos of my eye. I will let you know that about 13 years ago I went to a surgeon and he said it was the eye lid that was at fault and ‘drooping’, I did not agree, but I was 22 and I went with it in a desperate state to ‘fix’ it. He said he ‘crimped’ a muscle of my right eye lid and it did lift it but it looked even more obvious as it was not the fault of the eye lid. I can tell you this, and it sounds strange, but I know it to be true. When I was very young, I remember sleeping on my right side and the pillow was pushing against my eye ball and I remember thinking that I should not sleep like this, yet I did, and I didn’t move the entire night. In the morning my parents were very concerned and everyone at school noticed it and that is how it stayed. Years later I got eye lid surgery to ‘lift’ the eyelid. But i am VERY sure that the fault lays within the eye ball position and not the eye lid. I have looked, measured and worked out many things with my eye and I am beyond sure that it is the eye ball position in relation to the socket and the other eye that is off. You can clearly see that my left eye is flush against the ‘wall’ of the exterior [filling the entire area of lids upper and lower] and the right is somewhat ‘away’ from the outer corner, leaving a mm or 2 of ‘gap’. I want this fixed like no tomorrow. Now over to you and your expertise. Is this ‘fixable’?

A: Thank you for sending your pictures. In answer your question, I am first going to ignore what is a far more obvious deformity which is the difference in the horizontal position of the upper eyelids on the eyeball. You clearly had a right upper eyelid ptosis repair which has now left you with residual ptosis of the left upper eyelid which sits too low relative to the iris of the eye and asymmetric to the right upper eyelid. But since that is not your focus, let me address to what you are referring to.

Based on what I am seeing, the gap to which you refer at the corner of the right eye may or may not be due to the position of the eyeball. But the reality is that one can not move the eyeball from side to side so that is not a corrective option. To close that gap it would be far simpler to tighten or close down where the upper and lower eyelids meet by corner of lid tightening. That will bring the lid tissues in better approximation to the globe, thus eliminating the gap to which you refer.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have spent considerable amount of time in researching fat transfers believing it to be the most viable option when done correctly, especially for thin older women. The stem cell benefits of properly done fat grafting add tremendous benefits as well. I understand although fat grafting has been around for a number of years, the harvesting and injection procedures have changed, creating greater success in keeping the fat cells alive. What methods do you use to ensure the success rate of your fat transfers, and what is the success rate you are currently having?  One of the greatest difficulty for a patient, are the major disagreements in the medical field regarding the procedures used. Please understand I believe fat transfers to be one of the greatest positive changes in how we address aging skin, I want to have it done, but I am still very undecided due to the conflicting medical opinions out there. There is a very heated debate regarding the “dropplet” vs larger blocks, and the placement location.

A: The concise answer to your basic question is that fat grafting is in a state of evolution and development. It is far from a perfected science from the harvest to the injection methods. No matter what you read or is touted by any one surgeon, no one knows the best method to do fat grafting and just about everyone does it using the same basic principles. No matter what any surgeon claims, they do not have a magical method that works all the time and claims about how much fat survives, in many cases, are perceptions about fat graft take not actual measurements. How well fat graft takes can not yet be measured in any quantifiable way and is based largely on photographs and what the surgeons perceives has survived. Quite frankly as a surgeon I can tell that such perceptions are often skewed by what one wants to see and most claims of survival are likely overstated, some with good intent and others for pure marketing purposes.  What may work well in one patient and one face or body area may not work well in the next patient. Fat grafting by injection remains an imprecise art with the science lagging far behind as of yet.

The most straightforward and honest answer that I tell prospective patients about fat grafting take is…no one can predict it and it will likely end up somewhere between 10% to 90%. While the goal is to have have maximal take on one procedure, every fat grafting patient needs to be prepared that more than one procedure may be needed.

Most fat grafting is done by injection because it is the only practical way to either treat a large area or get the material without undue scarring. En bloc fat grafts, also known as dermal-fat grafts, actually work and take very well. But their uses are very limited because a donor site is required and the size of the recipient site must also be relatively small.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was interested in getting my hairline lowered as well as brow and frontal bone reduction. However I have a very thin hairline due to constant damage to my hair follicles. Any suggestions and how long after would I have to wait to get a separate surgery.

A: If I understand your question correctly, you would like hairline lowering/scalp advancement combined with frontal/brow bone reduction. The concern, which is both understandable and appropriate, is whether with a fine and thin hairline that you should have the procedure. The answer to that question would be based on what your frontal hairline looks like now (please send me a picture), how much scalp laxity you have and whether you were eventually planning on any hair transplantation along the hairline after the procedure. (as some people do for scar camouflage) The quality (hair density and pattern) of your frontal hairline determines how well the scar would do and its potential visibility. Your existing vertical forehead skin length and your natural scalp laxity determines how much scalp advancement/hairline lowering is possible and whether the result justifies the effort. Knowing that one may be considering the potential for hair transplantation later gives one more freedom to perform the procedure is someone with less than an ideal frontal hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would love to smooth out the under eye area- fill in the depressions created when I smile, and add an over-all fullness that I have lost, most recently in the last year as I have gone through menopause. I experienced a rapid and major estrogen deficiency that truly took a toll, especially in my face to appearing almost gaunt. (being a woman is quite a life-time adventure in of itself!) Looking at pictures just one year ago show a noticeable loss of facial volume even though I have experienced no overall weight loss or gain. Again, thank you for sharing your time and expert skill with me.

A: In interpreting your facial concerns they are two-fold: lower eyelid hollowness and a general mid-/lateral facial involution below the zygomatic body and arch bone levels. While both of these are caused by loss of fat, they may or may not be treated similarly. For the generalized facial wasting, the only effective treatment is fat injections. This is the only way to help restore larger facial surface areas that have no underlying bony support. (what I call the facial trampoline area) The lower eyelids are a bit different because the thin skin exposes the use of fat injections to risks of asymmetry and irregularities with so little interface of tissue between the lower eyelid skin and the underlying orbital bone. Other options include the use of orbital rim implants and dermal-fat grafts but those are not without their own issues. (more invasive, palpability, donor site harvest) Given these issues I would favor fat, whether it is of the injected or en bloc variety.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a chin implant put in and removed within a few months about 4 years ago. I have slight chin ptosis, and read about “routine” procedures to reattach/tighten/lift the chin pad, like what you discuss above, but when I google search, I find no one who does this . I have googled “raising the introral sulcus”, “correcting bottom tooth show”(no one seems to have any suggestions for this), “correcting chin ptosis”, “submental tuck up” (which you have also talked about) and get like 2 results. and those that do these procedures have like one photo on their website. I would also like projection higher up on my chin so that overhead light hits a small area on the chin, the rest in shadow. The implant I had before just extended the downward line of my jaw and increased the area that the overhead light would catch, making my chin look longer. I feel a feminine chin not only projects, but curves slightly upward at the end of the jaw. On your chin implant page, the 7th one down has a nice curve up, as do many of your patients, the 8th one down does not, nor does the one on the bottom of page 1–you just continued the downward direction of these jaws and I don’t think it looks right. How do you avoid that?? Thanks.

A: Correcting chin ptosis is anything but a routinue plastic surgery procedure. There is not much written about it because its correction is not easy and the results not always predictable. I have learned that the most predictable way to get sustained improvement is to do a lower periosteal/mentalis release, elevation of the chin pad by suture anchorage to a higher position on the bone, a V-Y lower lip mucosal advancement and a shortening vestibuloplasty. Combining all four maneuvers will always correct a some degree of a sustained chin pad repositioning and maybe some slight lower lip elevation.

Getting a chin pad that curves upward with implant augmentation depends on numerous factors including the presurgical shape of the chin pad, chin implant style and size (women usually do better with a central button style chin) and whether an intraoral or submental approach is used.

Dr. Barry Eppley

Indianapolis,Indiana