Your Questions

Q: Dr. Eppley, I find my nose too wide. I would like to narrow it a bit. I was also interested in having a cleft chin and anything else you suggest. Thank you so much.

A: Thank you for your inquiry. Your picture shows many of the features of the African-American nose, which is largely a broad and wide tip with lower alar cartilage flaccidity, flared nostrils and a low dorsum. Rhinoplasty changes would include dorsal augmentation, columellar strut graft, tip lifting and narrowing and lateral nostril flare reduction. Unfortunately the one picture that you have provided is not of good enough quality for computer imaging to show how these changes might look on you. Pictures should be better quality (not fuzzy), taken from the front and side view and be non-smiling.

Chin dimples are central round indentations on the central of the soft tissue chin pad. Chin clefts are vertical grooves that run from the center of the chin pad down to the lower border of the jaw. Either one made from an incision inside the mouth where a core of soft tissue (muscle and fat) is removed below the desired location of the external location of the chin dimple or a wedge of tissue removed along the underlying location of the desired chin cleft.. The underside of the chin skin is then sutured down inward to make the dimple or cleft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants. I am trying to find out pricing on getting implants and to see about payment. Most offices require full payment, however, I have heard of a few that will do payment plans. I didn’t know if this office was one of them?

A: When it comes to elective cosmetic surgery, including breast augmentation, you will find virtually no plastic surgery practices that take payment plans. A plastic surgery practice is not a bank or a credit agency that has any ability to finance and ensure that payments are received over time on a non-returnable service like surgery once it is provided. Full payment is required in advance of the actual surgery date. However, every plastic surgery practice recognizes that many patients can’t pay the full fee up front and work with independent loan agencies that do provide financing. One of the most common cosmetic surgery financing companies is Care Credit. You can go online with the amount you need to finance and apply and qualify. You can choose from a wide variety of terms up to 36 to 48 months. Many patients opt for the interest-free financing which extends out to 6 or 12 months. Our office has worked with many lending institutions over time but have found none that are as easy to work for our patients as Care Credit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have very large temporal muscles that I want reduced. They stick out significantly from the side of my head. It is not normal to look like this with such bulges. What is involved in reducing the temporal muscles. I have attached some pictures for you to see what I mean when I say these muscles are big. They might be great if they were biceps on my arms but not the side of my head!

A: Thank you for sending your pictures. That is one of the larger temporalis muscle hypertrophies that I have seen given the muscle size and the shape of the surrounding skull and orbital bones. It is no doubt all muscle and not caused by enlargement of the underlying temporal skull bone. You can confirm that by clenching your jaws and seeing the muscle striations and how much it bulges.

To reduce a temporalis muscle that is this large, a central wedge resection of the muscle must be done. This is accomplished through a vertical incision in the hairline on each side. The temporalis muscle fascia is opened and electrocautery is used to cut a large vertical wedge of muscle that parallels the muscle fibers out. The fascia is then reclosed. This will produce some immediate reduction in its size, not withstanding the temporary muscle swelling that will ensure right after surgery, but further reduction occurs up to six months after surgery as the muscle undergoes further atrophy. This is an outpatient procedure done under general anesthesia. Other than some temporal swelling and some stiffness on wide jaw opening, there is no significant recovery or restrictions after surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to improve the appearance of my eyes. My upper eyelids (just below my brow) have excess skin that hangs down, often pushing against my eyelashes. Also, I would like the canthopexy in order to make my eyes look more feminine. My eyes are very round, showing a significant amount of my sclera, and are angled down slightly at the outer corners.

A: The description of upper lid skin pushing on the eyelashes certainly indicates that an upper blepharoplasty would be needed to recreate an upper lid sulcus again. That is very straightforward and a standard periorbital rejuvenation procedure. Changing the position of the lateral canthus at the corners of the eyes can be done at the same time as the upper blepharoplasty. This is better known as a lateral canthoplasty as opposed to a canthopexy. In a canthopexy procedure the existing tendon is tightened by maintains its current position on the inner aspect of the lateral orbital wall. As a result, it tightens the lid margins but will not change their vertical orientation. Thus a lateral canthopexy will not correct a downward eye slant. A lateral canthoplasty, which relocates the insertion of the lateral canthal tendon up into a higher position on the bone is what you actually need to achieve your eyelid reshaping goals. That is done through the tail end of the upper blepharoplasty incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have bump on my upper ear that has been there as long as I can remember. My dad and sister have it also so it must be in my family genes. It feels firm but I can’t tell if it is skin or extra cartilage.While it doesn’t bother my other family members, I do not like it and want it removed so the rim of my ear is smooth. How easy is it to remove and will it leave any scar? It would not be worth removing if it left a scar which might be worse looking than the bump.

A: The bump on your ear to which you refer is incredibly common and is known as Darwin’s tubercle. It is a congenital thickening of the rim (helix) of the ear usually near the top at the junction of the upper and middle third of the ear. It is present in about 10% of all people and is inherited in an autosomal dominant fashion, hence your father and sister having it. It carries this name from the naturalist Charles Darwin who wrote about it in his book the Descent Of Man. He described it as a vestigial feature of man that serves as ‘proof’ of the link between man and primates. (check out a monkey’s ear)

A Darwin’s tubercle is an excess of cartilage that can be removed through a simple otoplasty procedure done from an incision on the underside of the bump. (inside of the helical rim) It can also be removed by direct excision of the skin and cartilage on the edge of the helix under local anesthesia. Either way, it can be removed without any significant or visible scarring. So scar concerns should not be a deterrent to having it removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple of questions about doing a genioplasty to reduce the length of my chin. First of all a vertical shortening of the chin would require an intra-oral approach, correct? Or could it be done via submental approach? Where would you rank this procedure in terms of potential risks and permanent negative outcomes? Als, how is it with European patients? Have you had people fly over from Europe before? And if so, how is the process concerning consultation, surgery and post-surgery follow-up? Is it possible to fly over for a consultation followed by surgery on the same, or one of the next few days? Or is an online consultation enough for you to assess the patient? Maybe an x-ray exam. is required for a procedure like the one I'm heavily contemplating?

A: In answer to your questions:

1) A vertical chin reduction osteotomy needs to be performed intraorally. The only risk of this procedure, besides have we achieved the aesthetic goal, is some temporary lip and chin numbness from the mental nerve which will be exposed in doing the procedure. While some permanent sensory loss is possible, that is not something that patients have reported to me.

2) We have many far away patients from all over the world so we are very familiar with how to manage them. As we are now doing, all of the details of diagnosis and treatment planning can be done by e-mail. My assistant will arrange for a Skype consultation as it is always good to talk, if possible, face-to-face from afar although this is not absolutely necessary. Surgery is arranged and then the patient arrives the day before and then we can meet in person at that time. Surgery is performed the next day and you should be able to return home within 48 hours. There are no sutures to remove and no real physical restrictions after surgery. Follow-up is done just as we are doing now by e-mail. From a chin osteotomy, expect some significant swelling for a few weeks after surgery but usually no bruising.

3) The only preoperative test that I would need is a lateral cephalometric x-ray so I can take measurements and see how much chin bone can be safely removed/reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had liposuction of my stomach and love handles three days ago. Within a day after the procedure, my genitals got really swollen and now are bruised as well. My penis and scrotum are extremely swollen, at least twice as big as they usually are. The shaft of my penis is bulging and hanging around the tip. There is bruising on the shaft that makes it look like it has gangrene. Is this normal and should I be concerned? Is there anything I can do to make it go down faster?

A: In men the most common areas to perform liposuction are the abdomen and flanks. The procedure induces a lot of trauma to the tissues underneath the skin and then the area is placed under compression with a circumferential wrap that is worn after surgery. Between this wrap and gravity, fluids including blood are forced ‘south’. Men have a convenient receptacle to receive these fluids known as the scrotum and penis. Thus it is not rare in large and aggressive amounts of male abdominal liposuction to have significant swelling and bruising of the genitalia. Because it can be quite shocking to see and always unexpected, I advise all my male liposuction patients to expect this postoperative phenomenon. It will peak at about 3 days after surgery and will be completely gone by 10 to 14 days later. It is not harmful no matter how it might look and is always a self-solving issue. There is nothing that you can do that will really hasten along its resolution.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been researching within the fields of plastic surgery for a while, searching for the ideal solution for my somewhat elongated facial appearance. I’ve ultimately concluded that I would probably benefit quite significantly from a chin reduction – shortening my vertically long chin.What I’m looking for, is to give my lower face a more angular and masculine look, whilst decreasing the length of my face. I’ve been very impressed by your work, and have decided to contact you first and foremost for an opinion or two on my appearance. I have a couple of pictures for you to look at, if you have the time.My front profile in original, compared with my photoshop-altered front profile to give you an idea of what I’m roughly considering. All I did, was reduce the vertical length of my chin. As you can see, doing so greatly improves my facial balance (At least that’s my interpretation). I hope you’ll take a look at these and give me your take. I’d like to know if you find my expectations realistic.

A: In reviewing your pictures and imaging, I would agree completely that your vertical chin reduction goals are very realistic. That is probably a 5 to 7mm vertical chin reduction by osteotomy and ostectomy and, as you have shown by your own imaging, it makes all the difference. It can be surprising how one simple change like vertical chin length can make a difference in how the whole face is perceived.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting a facelift but want a result that really lasts…like the rest of my life. I know that skin and muscle from the neck and jawline have to be lifted and removed and I am fine with that even though it scares me a little bit. But I don’t want to go through that if it doesn’t last a really long time. I have been reading about how stem cells are being used now and some doctors are doing a Stem Cell Facelift. This seems to make a lot of sense because one is not only getting rid of the loose skin but adding something that injects youth back in and can grow new collagen and skin. Is this a procedure that you perform as I am really interested to have it done?

A: The reality is that the use of stem cells in any cosmetic procedure, including a facelift, is both unproven but also illegal. (unapproved by the FDA) Stem cells harvested from patients have recently come under heavy scrutiny by the FDA and such potential cosmetic treatments are now regulated and restricted only to approved clinical trial settings. The widespread marketing of such procedures as Stem Cell Facelifts is now over and you will not hear much about them anymore. Their previous marketing and use was based on the appeal of stem cells and was both unproven and in some cases unsafe. Nobody knows what stem cells will do when transplanted into the body. This is illustrated by a recent report in Scientific American where a women injected with stem cells for wrinkles around the eyes developed bone in her eyelids. This demonstates that the effects of stem cells are not really understood and should be more carefully studied, as they are being done for many other medical condition treatments.

For now you will have to consider a traditional facelift procedure that has long been proven to be both safe and effective with results that last on average 10 to 12 years for many patients.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a pituitary tumor that made my skull grow very big. The pituitary tumor has been removed now and I am cured and cleared by my doctors. But the size of my skull is too big and very bothersome to me. It is very negatively impacting my self-image. My skull is too high up top and slopes down in the back. The temporal areas also stick out too far. How much skull reduction can be done to help me?

A: What I can tell you, with a lot of skull surgery experience, is that you can’t go deeper than the outer cranial table which often is anywhere from 5 to 7mms thick. Yours may or may not be thicker than that is some areas. At that point you enter the diploic space where a lot of bleeding occurs and the inner cranial table is not much further away. That is the limit of safety for any skull reduction procedure.

While 7mms may not sound like a lot of reduction, when done in a lot of areas of the skull, the external or visible appearance can be a lot more significant than the number sounds. It is common that patients think they need a lot more skull thickness reduction than they really do. I didn’t say that such a skull reduction result would be perfect or ever as much as some patients want. But is usually enough that patients feel it made a real difference.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My question is about jaw angle implants and tissue thickness. In previous blogs regarding questions about very angular jaw implants (medpor) vs standard silicone implants, you wrote that the medpor can indeed achieve a very sharp, angular, V-shaped jaw, but then you cautioned that SOME men will never be able to achieve this look because they have very thick tissues. My question is this: Normally, I have pretty normal jaw angularity. BUT when I clench my teeth together my jaw slightly widens and becomes VERY angular, V-shaped, and chiseled. Does this prove that my tissues are not overly thick, and that the right implant will succeed at achieving a very angular look?

A: What you are demonstrating is masseteric muscle contraction and the outline of the muscle fibers not the bony angle per se. But what that shows is that the overlying subcutaneous fat layer is thin enough so that the muscle outlines can be seen through the skin. That would be a favorable sign for being able to have jaw angle implants placed on the bone whose shape and angularity will be visibly evident through the external skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, In your experience what’s the least expected facial implant material to get infected? Also can maxillofacial bone cements or pastes be able to be used for the chiseled look? Also there’s a procedure where you cut the cheekbone and advanced the bone then added plates and screws can that give masculine cheeks/zygomatic arch look?
And does the bone grow into to the cut cheeks to reattach in case if plates ever needed to be removed? Is there any sort of special maxillofacial bone cut to the jaw to just add width and some drop down? Thank you.

A: While I appreciate the nature of your all of your questions, each one of them represents the same issue…you are searching for non-implant procedures to do what facial implants do. And the answer to all of them is the same…they either do not exist or do not work very well at all. There is only one bone procedure that replicates what an implant does..the sliding genioplasty. Otherwise, every other osteotomy/bone moving method works very poorly…and I know because I have tried them all over the years.

There are many factors that go into how implants can get infected so it is not as simple as one material is necessarily better than the other. If handled well, they all should have th same rate of risk of infectivity. But if I had to pick one just based on the material alone, it would be silicone because of its smooth and non-porous surface. It is harder for bacteria to get a good hold on this type of surface as opposed to a rougher irregular one like Medpor.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was interested in knowing if you perform the backlift bra line procedure? I can’t seem to get rid of these backrolls along my braline no matter what I do. I don’t think they are fat but just rolls of skin. I am also interested in a facelift. Can these be performed at the same time?

A: The Braline Backlift is a procedure that I am not only familiar with but have performed numerous times. It is usually done in most cases in the extreme weight loss patient but may occasionally be done in someone of normal weight or has lost a more modest amount of weight. It is an excisional skin and fat procedure which is done along the braline on the back through a double ellipitical excisional pattern. (it is important to not remove tissue across the midline spine due to adverse scarring) It is a tremendously effective procedure for eliminating those pesky back rolls and providing a bit of a ‘backlift’.  Think of it as a facelift for the back so to speak. It does result in a fineline scar that sits along the braline, hence the name the Braline Backlift. One has to determine if this scarring is a good tradeoff for the improvement/elimination of the backrolls.

There is no problem combining the Braline Backlift with a facelift at the same time.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I really wanted to advance my chin and make my jawline straighter. I know I will need a sliding genioplasty and perhaps bone cement along the sides of my jawline. I was wondering if what I had in mind is possible and have done my own before and after to show you whicih I have attached. I like how the part below my lip and above my chin comes out almost like the jaw was moved forward, along with the the extension of my chin and straightness of the middle part of my jawline. Is all of this possible ? I don’t want to use any kind of implant, just my bone and bone cement. Can you make a custom 3D implant mold and place bone cement in that instead of using an implant ?

A: What you are demonstrating is the classic change that would occur from a sliding genioplasty. There is no need for bone cement or 3D model fabrications to get there. The chin bone (not the jaw bone) is cut and moved forward and plated into position. While silicone synthetic implants can be made from a 3-D model you can not use bone cement to create an implant as it is too brittle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a few questions. Here's history on me I have had a sliding genioplasty in 2010 and a rhinoplasty in 2005 now I’m happy with the outcome but would like to get a more masculine chiseled look. But I would like to stay away from implants such as porex, silicone, goretex, etc. Can bone grafts be used or is there a way of augmenting without the use of implants? I think my jaw line will need some augmenting. Along with slight some in the chin for its narrowness/mild step offs. Maybe some in my supra orbital rims to give a stronger appearance. Thanks.

A: What you are asking for and how you are asking to do it can’t be done. There is no way to achieve those facial skeletal changes without the use of synthetic facial implants. While bone grafts can be done they are impractical for two reasons. First onlay bone grafts will completely resorb for the most part and what will stay, if anything,will be very irregular and unpredictable in shape. Secondly the amount of bone graft needed would be impossible to harvest unless large strips of outer cranial bone were taken from you skull. Thus the concept of bone grafts for significant facial skeletal augmentation is an unwise and ineffective approach to improving your jawline. A more effective autologous material would be cartilage grafts which don’t suffer much resorption when applied as an augmentation material. But I don’t think many patients want to have multiple ribs harvested from the subcostal margins for a cosmetic change. The reality is that what you don’t like (synthetic implants) is the best, easiest and actually safest way to achieve your jawline goals.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I appreciate you doing some computer imaging for my brow bone and forehead augmentation as well as a nasal implant to build up my nose. I have some general questions about these procedures for you

1. Is it possible to choose the exact shape of the augmentation I want? In the example photoshopped photo you sent me, I would prefer to have my forehead augmentation a tad bit less “round” and maintain a bit of a masculine ridge above the brows.

2. I’m wondering how precise can you get with the shape of the augmentation? Is it a matter of injecting the cement under the skin and molding it with your fingers? Or can it be matched to be pretty much what is shown in example photoshopped photos?

3. Regarding building up the nose bridge, how do you avoid the effect of the eyes moving closer toward one another? A bigger nose bridge means the skin on the bridge is pulled forward and therefore pulls on the inner corners of each eye right?

4. Will I have to open up my skull near the hairline in order to access the browbone? Is it possible to go through the nasal openings or perhaps eyelids instead?

5. I keloid very easily… will this be a major problem?

6. Regarding recovery, I’m sure there will be swelling and possibly bruising for a week or so, but how long after that is it noticeable that I’ve had surgery done on my face? If possible, I would like to avoid making it very obvious that I’ve had surgery done, as quickly as possible, without obvious scars.

7. I live far away, would it be ok to board an airline flight soon after the surgery?

A: In answer to your questions:

1) In the male having a brow ridge ‘break’ is important so that is something that I try to do with shaping a male forehead augmentation. By virtue of the way a forehead augmentation is done, the brow ridge break has to be be put by using a handpiece and burr after the material is set.

2) Forehead augmentations have to be done though an open scalp incision under direct vision. There is no method of injecting a cranioplasty material under the skin.

3) I am not aware that nasal bridge augmentation pulls the skin inward at the corners of the eye. That does not occur in a typical nasal bridge augmentation.

4) No as answered in #1 above.

5) Keloids are not a scar phenomenon that I have ever seen in the scalp or the nose.

6) The reality after this surgery is that it will take 2 to 3 weeks to look normal again and can not be done without a scalp scar. Having this type of surgery with ‘one week of recovery and no scar’ is not possible.

7) Most patients return home within 2 to 3 days after surgery by plane.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Help! I have got the saggest breasts ever. I am only 20 years old and am small at just 5’ 1” and 105 lbs. I have never been pregnant. Despite not having children, I have  very sagging breasts and am not sure the best way to get them lifted. Should I have implants or just have a lift? I am not sure I care either way although I might prefer implants because of the scar issue. How do I go about making the right decision? Thank you.

A: Your question is a common one and often illustrates comfusion about whether a breast implant can create a lifting effect. The asnwer to that question is yes and no. By filling and pushing out the breast skin envelope, the breasts can appear in some patients to be actually lifted. But the key question to this type of ‘scarless breast lifting’ is the location of the nipple before surgery. As long as it is above the level of the lower breast fold, an implant alone will create a lifting effect. But if the nipple is at or below the breast fold, no real lift will happen and the added volume may create the opposite effect of just pushng the existing breast tissue and nipple even further down. Your descriptor of ‘very sagging breasts’ suggests that you do have a low nipple location and a real surgucal breast lift will be needed. Whether that may include an implant for the creation of more volume is an option but the implant alone will not create the desired breast lifting effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about silicone vs medpor jaw angle implants. Forgive me if my question is silly, but I have only recently discovered the existence of jaw angle implants and am very, very interested. I am not only interested in widening the width of my jaw, but also of increasing the sharpness, angularity, and “chiselled” look of my jaw. In some before / after pictures on the internet, the patients' jaws are indeed wider, but they are still the U shape they were before. In other pictures, they are wider AND they are also the V shape–in other words, they have become much more angular, sharper, and more “chiselled” than before, not simply just wider.My question is this: I have read somewhere that only medpor implants can achieve this very sharp and angular jaw, and that silicone cannot achieve this. This is probably false information, but I am still a bit concerned about medpor if this indeed were the case, so my question is: Can silicone implants also achieve this sharp, angular and chiselled look?  Thank you so much, and I look forward to working with you.

A: Your question about jaw angle implants is nether silly or irrelevant. It actually speaks to a very basic difference befween styles of jaw angle implants, those that create width only and those that drop down the angle vertically and make it wider if desired. What you are referring to as increased angularity is the latter. As of now, Medpor makes the only jaw angle implant that adds this vertical dimension and comes in width increases of 3mm (virtually no width increase, 7mms, and 11mms) Silicone jaw angle implants do not come in this shape yet although that will change very shortly. I am designing these jaw angle shapes with a manufacturer in silicone currently.

I would caution you however that, regardless of any jaw angle implant style, the amount of definition seen is highly influenced by the thickness of the overlying soft tissues. Some mem will never be able to have highly defined jaw angles if their tissues are too thick.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting maybe a mommy makeover. I have 2 kids, tubes are tied and I plan to have no more! I have a terrible big flabby stomach and my breasts are saggy :'(  I got pregnant and thought it was a time to indulge. I wanted to have a chubby baby so I ate a lot. Gained almost 100lbs during my pregnancy. In the end my baby wasn’t chubby (weighing only 7lbs 11oz) but I was left with stubborn fat that won’t go nowhere.  I don’t want bigger breasts though, my breasts are big enough, I would honestly maybe even like them a cup or more smaller but as long as they sit right on my chest they may just look better with possibly just a lift.  I want my stomach flat again though. I am a thicker woman. 5’8″ 230lbs. I plan to lose some weight though (I’m working on it) prior to having these operations done. What would this cost? Could I pay like… $4000 then the rest in payments? Is that offered for operations, as these? How much weight do you think I should be before having this done? I don’t smoke or do any drugs, I drink occasionally but overall healthy, just overweight, or obese, I guess I should say… Please help me to feel better about myself again. PLEASE!

A: Thank you for your inquiry. While I will ultimately need to see some pictures of your body or see you in an actual consultation, let me provide you with a few thoughts/recommendations based on the description of your concerns.

From a breast standpoint, you are describing a classic full breast lift. This will leave most of your breast tissue but will significantly tighten and lift your breasts back up on your chest wall and center the nipple on the newly positioned breast mound.

From an abdominal standpoint, you most likely need some version of a full tummy tuck to get rid of any skin overhang and make your stomach flat again. Whether this is what we call a full tummy tuck or an extended tummy tuck awaits my visual assessment of your body.

Putting any form of breast and abdominal reshaping garners the moniker of a Mommy Makeover, changing what has been affected by pregnancy the most…one’s breasts and stomach area.

When it comes to weight loss before a Mommy Makeover, a general rule is that one should be between 15 to 25 lbs of their desired ‘realistic’ weight goal. Notice that I didn’t say your ideal body weight which for some patients is not a truly realistic goal.

I will defer cost estimates to my assistant. But cosmetic surgery is never paid in installments which is more typical in the banking and retail industries. We have no means to reclaim the surgical results if the patient defaults or fails to pay after the work is completed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have jaw angle implants placed on both sides. Even though I have jaw angle asymmetry, getting custom implants is currently out of my budget.  Do you think I could still get great results with doing a CT scan and having you pick “off the shelf” implants based on my CT scan?  Or would I be better off coming back in a year or two after saving up?  Also, what about the possibility of using this “artefill” permanent filler instead of an implant?  Do you have any experience with that?

A: What you are referring to is using a combination of a your jaw model from a CT scan and using off-the shelf implants to get the best result. That is what I call a 'semi-custom facial implant' approach in which the stock implants are modified before surgery on the model. An advantage with this approach that you do not have in surgery as you can never see the jaw angles in full detail and certainly can't really compare their anatomical differences. A semi-custom approach is reasonable if the anatomical problem is really one of asymmetry and the changes desired do not exceed what off-the shelf implants would normally do. In other words, you can do some adjustments to the shape and size (reduction) of the implants but you can't add to them. If one is looking for changes that go beyond the scope of existing shapes of current implants then only truly custom-fabricated implants will do. My perception is that you probably fit more into the semi-custom jaw angle implant approach.

As for 'permanent' injectable fillers, that does not really exist. No injectable filler, Artefill included, is a permanent filler. (if you do it enough times, some permanency of the result will occur due to its non-resorbable PMMA bead content) But on a practical basis, and I will assume that you can get a similar result to a facial implant (which you really can't), the cost of the filler based on volume needed will have allowed you to have had custom facial implant surgery…for a result that is not equivalent. The real role of injectable fillers as a substitute for facial skeletal augmentation is a temporary trial to see if augmenting any facial skeletal area is worth actually having the real surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eyelid surgery (I'm Asian), nose surgery, jaw surgery and I have a small skull. I want some plate inserted to make my head fuller as I cannot tie back my hair without looking awful with small skull and square jaw. I need help as my self-esteem is very low and just can't accept my aging.When I was younger, I had a long face. Now that  I am 43 years old my jaw got wider. I am short and this just makes me look uglier. My skull is small and flat on top for my face. I am okay with the back of my head. I want  a fuller top without teasing up my hair to make my face proportional. I would like to be able to tie my hair back and tight without my face looking big and wide. I would like a deeper set of eyes and nicer nose too. I have expression lines across my nose. I wake up early for work and the fleshy eyelids means a lot of space for water retention. I have attached pictures for your review and thoughts.

A: Thank you for sending all of your pictures. Let me start by reviewing your requests based on the pictures that I see.

1) Eyelids – I see that you do have a high eyelid crease that is now overhanging with skin. I suspect given your ethnicity that you have always had a slight overhang with a crease but the skin is now overhanging more. Removal of the overhanging skin would be indicated which could be done to leave a little residual overhang or have no overhang at all, whichever is your preferred aesthetic result.

2) Nose – With your nose shape and ethnicity, the typical aesthetic goals would be a higher bridge and a narrower and more projecting nasal tip with possible nostril narrowing. Computer imaging will be needed to be certain of your exact aesthetic goals.

3) Skull – Based on your description, you desire a higher cranial height at the top located more to the back of the head. (vertex) This could be built up using a PMMA material with an increased height of approximately 10 to 15 mms using my standard skull reshaping techniques.

4) Jaw – Your wider lower jaw is as common ethnic feature that could be improved by either muscle reduction by Botox injections or jaw angle width reduction by lateral ostectomies. Given that these are rather different treatment approaches (noon-surgical vs surgical), it would be very important to have a precise understanding of your exact goals and their importance in this facial area.

What I would like you to do is to review these points, give me your thoughts on each and establish a list of  the most important to least important changes on this list.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had both buccal fat pad removal (10+ years ago) and cheek implants (6 mos ago).  I'm now considering fat transfer to go over my cheek implants since that didn't seem to add enough volume. I was also considering perioral mound lipo, but I have a concern that I hope you can advise me on.  Ever since my buccal fat pad removal (10+ years ago) I've felt a constant throbbing in my cheeks, the Dr. that did my cheek implants said it was likely due to nerve damage.  Do I face a higher risk (than the typical person) of further nerve damage because of this?  If further nerve damage did occur, what would be the extent of it? i.e., do I run the risk of paralyzing all the nerves in my face, or having thick scar tissue, or…??  Also, do you think with the fat transfer that I could look like I did before?  My goal is to not only look like before, but also go back into modeling and acting. I very much like your website and it seems you have a lot of experience.

A: Knowing your prior facial surgery history explains your younger appearance with the indentation in the submalar/buccal fat pad space from an earlier picture. Since you had cheek implants just six months ago, that explains several current findings. First, the throbbing that you feel in your face is not likely nerve damage. The nerve that runs around the  buccal fat pad is a branch of the facial nerve which is partially responsible for upper lip and nostril movement. If that nerve was damaged you would have some observable facial weakness not a throbbing sensation. The most likely reason you feel a throbbing sensation is the loss of the buccal fat pad which helps buffer the pulsations from a large branch of the facial artery that crosses around it. You always have to remember that the buccal fat pad was there serving some purpose. Thus your face is not at any higher risk of further nerve damage no matter what additional procedures that you may undergo. Second, if the cheek implants didn't give enough volumetric addition that would indicate that the style or size of your current cheek implants is inadequate. When considering additional cheek augmentation, your options would be an exchange to cheek implants that have more projection (much easier the second time around because of the existing pockets) or fat injections. Each of these has their own advantages and disadvantages. While you can certainly put fat injections above cheek implants (not actually on the implants) there is always the unpredictability of how much fat will survive. But certainly fat injections are easier with next to no recovery other than the temporary acceptance that they will be a little too big, compensating for some injected fat absorption in the first 6 weeks after the procedure. That combined with perioral mound liposuction creates a complementary cheek effect.

In terms of can you get back to exactly to how you were when you were younger, I would say no not exactly. At best I would anticipate you would get closer but never exactly that exact look again as you are now older.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to look younger and more attractive. I used to get comments that I looked so much like Angelina Jolie. I don't get those compliments anymore. One of the attached photos is me when I was younger. The other one is me now. I need some cheek sculpting to bring my now fat cheeks in more.

A: Thank you for sending your pictures. The difference between you now and when you were younger appears to be wide or 'fatter' cheeks with loss of a high cheek definition look. This could be caused by aging (falling cheek tissue) or increased fat collections in the lower cheeks with age and some potential weight gain. Careful analysis of your pictures shows that the main difference is inversion of the soft tissue cheek triangle. When younger the cheek was an upside triangle with most of the fullness up top and the apex of the triangle down below inverted inward. With time the triangle has inverted with the base of the triangle now at the bottom of the cheek (most fullness) and the top of the triangle up high over the cheek bone. (Ileast fullness) To attempt to rearrange this soft tissue triangle the following needs to be done…buccal fat pad extraction and relocation to the cheek bone (like placing an implant) or cheek fat injections and perioral (lower cheek) liposuction. In essence, add fullness over the cheek bones and remove fat below the cheek bones. Since fat changes are the crux of the facial problem it makes most sense to undergo a fat redistrbution surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have attached a number of pictures of my wife. She has a prominent forehead dent that is very bothersome to her. It even makes her appear more serious or even angry at time even though she is not. What could have caused this dent in the first place? What can be done for smoothing this out for my wife? I didn't really think that something can be done for this type of forehead issue until I came across your website. Thank you very much for your help.

A: Thank you for sending your wife's pictures. I believe what your wife has is known as linear scleroderma. This is a rare craniofacial condition in which the fat under the skin largely disappears and the overlying skin gets thinner. What is unique and easily identifiable about this condition is that it often occurs along a very distinct line. (hence the name Linear) While it can occur anywhere on the face, when it occurs in the forehead it appears as a straight line running right down the middle of the forehead vertically from the frontal hairline to the eyebrows. It always appears, as in your wife's case, as an indented vertical groove in the forehead. This is not a bone problem as the underlying forehead bone is usually normal. The groove is due to a soft tissue deficiency. (hence the name Scleroderma although this is not associated with the more generalized autoimmune disorder of scleroderma) It is not known why this unique soft tissue deformity actually occurs although it has a fairly classic presentation. It is not present at birth and only begins to appear in late childhood or teenage years. Its progression usually stops by early adult hood and progresses no further. (the indent does not get any deeper)

Treatment of a forehead linear sclerodermal defect is about soft tissue augmentation, building up the forehead indent from underneath the skin. I have treated them by a variety of soft tissue methods including fat injections and the placement of allogeneic dermal grafts or dermal-fat grafts. Any of these procedures can be completed in one hour of surgery. It may takes months to see the final result, in terms of volume retention and smoothness, as the fat or dermal graft survival integrates into the surrounding soft tissues.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 33 year-old female with three children, ages 9,7 and 4 years old. My last two deliveries were done by c-section. I love my c-section scar because it is low and very hard to see. I want to get rid of my abdominal pooch, loose skin and a belly button that sticks out. I want a mini tummy tuck because I would like the least scar possible and have it no bigger than my current c-section scar. I also want my muscles tightened because I have that pregnant looking pooch. I really don't want a scar around my belly button. Basically, will a mini tummy tuck accomplish all of my abdominal goals? Is this realistic?

A: The simple answer is no. You are asking out of a mini tummy tuck what a full tummy tuck does. What you want is a full tummy tuck result but only want the scar burden of a mini tummy tuck. I can’t blame you for having a lofty plastic surgery goal but it is not achievable. The reality is that one can not have both and you will have to choose which one of the two tummy tuck choices offers a trade-off that you can live with the best. In essence if the small scar of a mini-tummy tuck is the most important part of having the procedure then the trade-off will be that of incomplete correction, some remaining pooch and residual loose abdominal skin. Trying to keep the scar so small simply limits how much correction you are going to get. If the maximal amount of abdominal correction is what is most important, then the full tummy tuck should be done with the trade-off of a longer and higher final scar. (and a scar around the new belly button as well)

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 42 year-old white female who has the beginnings of lip lines. I don’t smoke and have never tanned excessively. I have fairly pale skin. While my lips have never been really big they have never been thin either and have always had good shape. I have noticed over the past few years that I am getting several noticeable lines in my upper lip. My lipstick now is starting to bleed into the upper lip along these lines. My lips still have some shape but they are beginning to lose their shapes. What can I do to get rid of these lines and get some plumpness back to my lips?

A: Vertical lip lines or wrinkles are one of the peskiest facial aging problems. They are not easy to treat and they are relentless…always fighting to come back no matter what is done. Lips lines, like all wrinkles, appear because of underlying muscle action. The mouth is encircled by a ring of muscle known as the orbicularis oris. Anytime you pucker your lips or suck on a straw, this muscle is activated and contracts. Wrinkles appear on the overlying lip skin perpendicular to the direction of the muscle movement, thus the appearance of vertical lip lines. The thinner the lips one has (most common in Caucasian females), the more likely that lip lines will appear. Since it is impossible and impractical to completely stop moving your mouth (although not sucking on a cigarette or water bottle helps), treatments must be directed toward either inducing some muscle weakness (dilute Botox injections) and/or plumping up the lips by injectable fillers. In more advanced lip aging with a greater number and deeper lines, laser resurfacing or dermabrasion must be considered. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, five years ago I had a sliding genioplasty to increase the projection of my chin. The titanium plates and screws are still in place. Although I am very happy with the new projection of my chin, I would like to have a decrease in the vertical length of my chin. Is it possible to simply cut out the bone below the titanium screws (below the red line on my x-ray pic) My surgeon told me that there are special muscles attached to this area and for this reason this wouldn´t be possible. This would lead to a droopy chin. He told me that vertical reduction of the chin could only be achieved by cutting out a horizontal slice of bone between the chin. What is your opinion on this?

A: To decrease the vertical height of the chin, if you are using an intraoral approach, it would be better to redo the horizontal osteotomy for the sake of keeping the soft tissues attached to the underside of the chin bone. The challenge in repeat sliding genioplasties is not the bone cut or removing the needed amount of bone but getting the old plate and screws out. Sometimes this can be next to impossible particularly if more than one screwheads sheers off. It is for this reason that removing a wedge of bone on the underside of the chin is appealing. Knowing how to reattach the muscles (mentalis muscle resuspension) is the  key to successfully using that approach for vertical chin reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am undergoing scar revision from a bad forehead injury and my plastic surgeon said he would use forehead skin mobilization? I looked it up and only one example came up. Will this technique move my current scar in a different direction? How big would my new scar be after the direct scar excision? When I think of the word total forehead mobilization I think of my forhead being lifted and moved around. What does this mean and how does it work to improve the appearance of the final scar? I was initially interested in tissue expansion help my forehead scar but my doctor said that was too extreme and didn’t need to be done for my smaller scar issue.

A: Tissue mobilization means the tissues around the scar are freed up so that the wound closure after scar excision is not tight. Tension is the biggest enemy for maintaining a narrow scar and is undoubtably why many initial excision ended up with scars the re-widen afterwards. This is particulalry true in the tight tissue of the forehead. Tissue mobilization is a technique to make more tissue around the excision site available for wound closure. It is in some ways a poor man's tissue expansion method. The location of the scar does not change nor will it be any longer when subperiosteal tissue mobilization is done in forehead scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My head is very flat in the back (there is even a huge indent) which I believe has caused my head to grow wider from side to side than from back to front. My forehead is an odd shape and the top of my head is flat. Overall, I want to achieve a more oval shape to my head- less wide with a little more height to the top.

A: Thank you for sending your pictures. Based on the way you wear your hair in the back, I am assuming it is in a bun to mask the flatness. Generally with the back of the head is flat, the skull growth compensates by make it wider, so this is very common. With a wider skull, its height does need to be as high. So your overall skull shape fits for how it has developed. When changing a skull shape, the 'easiest' thing to do is to add volume. Volumetric skull additions can be more substantial (10 to 15mms) than skull reductions which are usually limited to around 5mms due to the thickness of the skull bone. Therefore the forehead and back of the head can be augmented with some minor reduction in the posterior skull width.  This would definitely achieve a more oval shape to your head. When doing both the front and back of the head for skull reshaping, a bicoronal incision is needed to perform the surgery for adequate exposure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What easy is it to remove a chin implant I've had since 1993. It wraps halfway round my jaw and  the muscle appears loose or detached one side of my chin and now have TMJ on that side (jaw locking, clickling . pain). I've never liked the implant and looking at old photo I didn't need it. Its given me too strong of a jawline and a longer face.

A: Certainly after nearly twenty years you have a very good idea  of the benefit (or lack thereof) of a chin implant. Removal of an undesired chin implant is a lot easier than originally putting in. This is a simple extraction of an implant inside an existing pocket as opposed to creating a new pocket under the periosteum done during its original placement. This eliminates most of the pain, swelling and discomfort from the procedure. Because of the chin implant’s age, it undoubtably is silicone and not that big. You may think that it wraps halfway around the jawline but that would be very unusual in the early 1990s as so-called wrap around chin implants were not yet commercially available.

While removal of a chin implant is very straightforward, particularly with a silicone material, there is one consideration to look out for in its removal…a sagging chin pad or witch’s chin deformity afterward. This can occur when the implant is very large and provides a lot of support for the chin pad tissues. If this is a potential risk then the chin pad tissues will need to be resuspended at the time of implant removal to prevent this aesthetic complication.

Dr. Barry Eppley

Indianapolis,Indiana