Your Questions

Q: Dr. Eppley, I wanted to get your advice about having an additional migraine surgery. I have been very happy with the results from the bilateral zygomaticotemporal nerve decompression procedure. I have continued to have pulsing in my temples. I also feel a pulsing sensation in my ears. Most days, I do not find this pulsing to be painful. This is quite a remarkable improvement given that I was experiencing constant pain prior to seeking treatment with you. Do you think that auriculotemporal nerve decompression might relieve this pulsing sensation? Also, is it possible that I have developed a secondary trigger point in my forehead because I had started to have pain in my forehead. I actually had a sinus infection in my left maxillary and left ethmoid sinuses and had sinus surgery in September. I still have a little bit of pain in my forehead, but I think that this might not be an issue.

A: I am glad to hear that you have continued to have persistent migraine relief, even if it is not completely cured. The pulsing in your temples and ears, and I am assuming this is new since your surgery, strikes me as more vascular then neural. Ligation of the main trunk of the superficial temporal artery as it crosses into the temporal hairline as well as ligation of the posterior superficial temporal branch would seem to be a more logical approach than auricultemporal nerve decompression although that would inadvertently be done at the same time at the same time with the ligations.

It is not uncommon that improvement by decompression of one trigger point unmasks a secondary contributing one. This is most common between the supraorbital and zygomaticotemporal trigger points. Their close association makes a contributing connection between the two anatomically likely. It is hard to know, because of its anatomic proximity, as to whether your recent sinus surgery has a contribution to your frontal/forehead discomfort. The simplest way to find out is to do a few units of Botox around the supraorbital nerve and see what happens to the forehead discomfort. A positive response to Botox would mean that supraorbital nerve decompression may be beneficial and that the sinuses are not making a contribution to your discomfort.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, you have done some Botox for me in the past. We discussed that I was one of the few people who didn't respond very well to the Botox. You said maybe because my forehead muscles are too strong or some other reason. Whatever the case may be, I would like to know what option I have to get rid of the deep “angry eyebrow” wrinkle. Is the only option to go under the knife?? Thanks.

A: To review your forehead/glabellar furrow issue, it is not that  Botox didn't work. Botox always works but its mechanism of action (muscle weakening) was unlikely to correct what is now the main problem with your furrow, it is so deeply indented from years of muscle overactiivty that the skin is now permanently etched or grooved. This is beyond being ideally treated by muscle weakening (although it was worth seeing how much of a difference that could make) but now requires some form of skin management for improvement. For patients with these very deep grooves or furrows in which Botox fails to provide any significant improvement, the furrow can be treated by a variety of options. The simplest and most common is an injectable filler (e.g., Juvederm) to plump it out and soften its depth. This is often done either after Botox has 'failed' or in combination with it. (the filler lasts longer if it is not pounded on by the muscle movement that caused the problem in the first place) All current injectible fillers are temporary and do not create a permanent filling result.  Another filler approach is to place a small tubed implant under the skin to create a permanent filler. The tubed implant, Permalip, is the same type of permanent implant that is used in the lips, nasolabial or labiomental folds. Another permanent option is to excise the furrow and treat it like a geometric scar revision. By cutting it out and putting the skin back together in an irregular fashion, the furrow is made smooth. All of these treatment options can be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a depressed forehead scars right in the middle of my forehead, parts of which contain pigment from a previous birthmark removal. I am desperate and need a doctor to help me. I know you are one of the best and I trust your opinion. I was researching and thought that the use of tissue expansion may be hekpful in its removal. I figured you can make the insision through my eyebrow for the flap/scar for the tissue expander. I am also interested in hair line lowering but not sure you can combine both procedures. I am open minded to ideas .I just need this fixed.

A: Thank you for sending your pictures. Your forehead scar is more vertically-oriented than circular perhaps from a previous surgical excision of a congenital nevus, hence the residual pigment. Regardless of its origin, let me clarify for you some basic misconceptions that you have about its potential surgical improvement. First, tissue expansion is a reconstructive technique that is way beyond what is needed for your scar revision. While it is a wonderful reconstructive technique for creating more forehead skin, your scar problem does not merit such an aggressive approach. In other words, the magnitude of the solution (tissue expansion) does not match the smaller severity of the problem. (scar) When such mismatches occur, other aesthetic issues arise that are usually worse than the original problem. in the case of tissue expansion, this means a larger scalp incision is needed for its placement (and an additional scar elsewhere), it requires a two-stage surgery (cost) and the inconvenience of walking around with an obvious mass in the middle of your forehead between the first and second surgery for a few weeks. (plus you have to be able to do the daily or weekly tissue expansion by needle on your own) Secondly, no access to the forehead can be obtained through the eyelid or brow area. There is a large nerve there that would have to be cut to do it giving you permanent forehead and scalp numbess. Plus an eyelid incision is neither big enough to place a  tissue expander nor is scarless in someone with substantial skin pigment. (postoperative scar hyperpigmetation)

On a more practical basis, what you need is a much simpler approach…direct scar excision with complete forehead skin mobilization (done through the scar) to alleviate tension of the forehead skin closure after the scar is revised. This could easily be combined with a hairline lowering/scalp advancement procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding skull-shaping. I have a bump on the top of my head and the back of my head sticks out way too much. I am hoping to get these areas reduced so that my skull would have a more round shape. I want to know if this amount of skull reduction would be possible at all. Here's a picture to show you what I'm thinking, not necessarily the exact way I did it but something along those lines, what would be realistic?

A: Thank you for your inquiry. The areas of the skull that you show you want reduced can be reduced, it is just a question of magnitude. Generally speaking up to 5mms of outer table skull thickness can be reduced in most patients. Probably what you are showing is a little more than that so exactly what you are showing is not realistic But I have seen some signficant external changes occur when only 5mms is reduced, particularly when two skull areas are being reduced. That amount of skull reduction may not sound like much but often is more visible from the outside than what that number may seem.

Q: Dr. Eppley, I understand that recontouring of the frontal bone is a procedure that is not often done in male patients due to the scalp  scar. The problem that I have is that the upper portion of my frontal bone protrudes over the supraorbital ridge.  In addition to this, I have an evident asymmetry in the area of the superior temporal line on the left side of my skull. My question is would these two issues be capable of being addressing by burr and synthetic materials as appropriate, and as for the required incision, as an alternative to a coronal flap incision, would an incision on the back of the head be used so as to conceal the scar given the possibility of male pattern baldness?

A: In answer to your question about what type of incision may be possible in a male for brow bone and/or forehead surgery, the picture of a potential incision you have shown (the wrap-around occipital incision) is not one that can be used. While anything can be done on a drawing or on paper, it is impractical to use for brow bone or forehead surgery. To really reach this area and work on it adequately, the scalp and forehead tissues must be 'flipped' down to see the area. That incision is so far back that it would be difficult if not completely impossible to work under so much scalp tissue from so far away.  This is more than just theory for me as I have tried such incisional approaches and can testify to the difficulties that they pose. The problem is not that you can not access as low as the brow bone area with am occipital coronal incision, it is that any bone modifications or material additions that one does becomes very hard to get them smooth or even at such a distance. And if you don't have some assurance that a good aesthetic improvement can be obtained then that defeats the purpose of doing the operation in the first place. That being said, if the back end of the incision is moved up by 5 to 6 cms in the high occipital area, then it can be used for brow bone or forehead modifications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I always felt I had too much skin  in my neck and as you can see from my pictures I have no jaw line and I must have too many platysma  muscles causing  me to have this large oversized  neck. I have the neck of a 80 year old and have had this since I was 19. If you look at my high school year picture it is not too bad but for some reason after I hit 20 my skin just got more and more loose in my neck. It just sucked. Which is why I can never wear a hat as all you see is my multiple chins. I hate  the fact that I have this old man neck and have had it all these years. If I gain an ounce its always in my neck and face. Just fyi, I’m 5'10 and 219lbs. My BMI or fat percent when I am training  regularly is 19 which is not bad. But when I slack off it’s between 25 to 30. I really just want too get rid of all  this loose skin and for once in my life be able too wear a hat!!! Does it take long too recover since I am embarassed and don’t want anyone to know. Have you seen this Lifestyle Lift advertisement? Would that help? Thank you so much for looking into this for me, greatful for your time. From a guy with too many chins.

A: The problem is your neck is not just loose skin or 'too much platysma muscle' (such a thing doesn't exist), it is a combination of anatomic factors including loose skin, subplatysmal and supraplaytsmal fat, a high hyoid bone and a mildly recessive chin. The one thing you absolutely don't want to do is the Lifestyle Lift. That would be a waste of money for you because that is an operation that is too small and inadequate for your neck problems. That is really a limited form of a facelift that is good for jowling problems but is inadequate for you neck concerns. What you really need is a neck-jowl lift combined with chin augmentation with aggressive work in the submental/subplatysmal area. (all part of what is more commonly called a facelift) That is the only approach that will have any chance of making a significant change. Do not waste your time or money searching for other solutions that appear simpler and easier…because they will not work for your anatomic neck problem.

When you look at recovery from this type of operation, it is going to take two or three weeks to look pretty good again and you feel comfortable out in public. So it is a commitment on your part to make this change. Yours is not a neck problem that will be fine in a few days or a week after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old male and have been interested in seeking surgery to improve the area surrounding my eyes without detracting from my masculine features. I have searched tirelessly to find an oculpplastic surgeon which will help me achieve my desired result without feminizing my face. This search has involved me meeting with a number of surgeons, none of which are familiar with inferior orbital rim implants. It has been recommended that I would benefit from upper and lower blepharoplasty with arcus marginalis release and fat transposition. It has also been proposed that I would benefit from malar implants to address my flush cheeks. I am particularly interested in skeletal augmentation with inferior orbital rim implants and malar implants- do you practice with these techniques and implants?

A: As you are aware there are different techniques and surgeon’s have different philosophies as to how to manage the deficient lower orbital rim/tear trough deformity. But when combined with a more recessed malar prominence, this indicates there is an overall infraorbital-malar deficiency. When the underlying skeletal deficiency is more extensive, as you have described, I would agree that a skeletal augmentation approach is the more effective and better long-term solution. In my experience, I treat these skeletal deficiencies with a combined Medpor malar-infraorbital implant placed through a lower eyelid incision. This is the best style of implant that I have ever used for this exact problem. I have placed this implant through an intraoral approach but it is very challenging to get it positioned properly above the infraorbital nerve. The maximum projection of this implant at its malar portion is 4mms which is usually adequate for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When I was six years old I had a serious road accident and fractured my chin bone, as I was so young, and we are going back to 1987 healthcare, they stitched me up and let me heal naturally although as I grew to a teenager I developed an under bite, not severe but definitely noticeable until as an adult by shire luck my face filled out and a regained a natural bite, with I might add straight teeth. Every so often however, if I have had a throat infection I have sometimes gasped in pain with accidently knocking the region just tucked to the back of the chin, I believe known as the Mentalis muscle. It certainly feels very central and extremely tender. I wonder whether 1) Is sensitivity normal around the mentalis and 2) Would it be wise to get the area Xrayed or CT scanned to check for tumour if it does feel like a lump has developed in the region? Looking forward to your expertise.

A: This sounds like you had an original non-displaced symphyseal fracture through the chin. It would be normal to not treat these surgery unless there was displacement of the fracture, particularly at 5 years of age. I doubt very highly that you would have developed a 'tumor' from this fracture but there is only one way to know for sure. Get a screening panorex x-ray first and see what that shows. This is a scout film of the jaw that provides a good view of the chin and will show if there are any bony abnormalities. If this film is negative then I would doubt a CT scan would be more useful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am much concerned about my underdeveloped jaw and need your expert opinion on it.  I am in a phase in my life in which I suffered from muscle wasting. With these pictures, I have few questions that if this is really a serious aesthetic problem? If it can be converted into a square jaw and how?

A: Thank you for sending your pictures. More square jaws are created by a combination of chin and jaw angle implants that create a stronger and more angular jawline through their size and shape. For more standard cases where one does want an extreme change, stock or off-the-shelf implants are used. In cases where the patients want a more extreme change or want to do the jawline in a wrap-around fashion so it is completely smooth from one jaw angle to the other, then custom jawline implants are used.

I would love to show you these examples on your face but your beard would camouflage most of the effects or at least obscure many of the most significant changes. I suspect in looking at your pictures that stock chin and angle implants would work just fine…although the strength and magnitude of anyone's jawline goal is a personal one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two double-jaw orthognathic surgeries that didn't cause any lasting problems to the sensation in my nose or upper lip, but this last surgery did. Ever since the last surgery, the area just inside and under my nose is constantly aching and my upper front teeth and gums are still numb. Could the hardware that that I've circled in the panorex x=ray be causing these problems for me? Do you think that removing this hardware could resolve it? I'm asking because even if I don't have more jaw surgery, I don't think that I can stand this aching/burning/numb feeling inside my nose and upper teeth much longer. I was on Tramadol for several months and then switched to Lyrica – but nothing really helps.

A: While titanium plates and screws are non-ferromagnetic and do not corrode, the location of the metal hardware could certainly be a contributing cause as it is positioned around the pyriform aperture directly above the tooth roots and at the base of the nose. While most LeFort osteotomy patients do have hardware in similar areas, the right-sided location of the hardware does cross over the premaxilla more than is customarily seen. While no one can say for sure if this hardware is the cause of your dysesthesia, there is one way to answer that question definitely…remove it. I would remove both medial or paranasal maxillary plates and screws to be sure all devices are gone from the paranasal areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 52 year old white male 5'9″, 165 pounds. I have had a hair transplant and ears pinned back in 2002 and nose job way back in the in mid '80s. I have a very strict diet and workout extensively and have developed a very msucular physique, particularly for someone my age. I am concerned with my face as I am interested in male model look. What do you think could be done to make my face more aesthetically pleasing, proportional, etc. more in line with a male model type of look? I am very curious to see a computer projection of your proposed procedures. Thank you.

A: The first thing that I observe is that you have a body physique and msucular definition (to your credit) but the face doesn’t match it. While age never helps any face, your facial proportions and skeletal structure is not as robust/proportioned/chiseled as that of your body. Thus there is a mismatch and I can see why this has become an area of interest to you.

When it comes to the so-called male model look, what that means is defined facial skeletal structures or highlights of the facial triangle, the cheek, jaw angles and chin. Augmenting these three areas is what is usually done to create a more defined masculine facial structure. While your chin has reasonable projection, your jawline and face is narrow. I have done some imaging based on jaw angle augmentation, cheek implants and a square chin implant. None of your pictures are really great for imaging due to their quality, angles, lighting and facial expressions but at least they give a general idea of the effect. Be aware that computer imaging is really just a point of discussion and communication of the desired effects and reflects only one variation of the potential effects. There are magnitudes of potential change and this first set is just a starting point.

When it comes to your eyebrows, you have all of the issues that must be considered for any male browlift patient. Because of the absence of a hairline, none of the traditional browllift approaches can be used. (through the scalp) Thus most men need an upper eyelid approach (transpalpebral) with release of the medial muscle around the nerves to get sosme inner lift and relaxation of the glabellar musculature and a lateral brow lift using an endotine device. The ‘below the brow’ approach, which by necessity must be done in most men, only produces a modest brow elevation. But that usually turns out to be a good thing as one of the most unnatural and peculair looks in a man is an over elevated browlift. (e.g., Kenny Rogers, Bruce Jenner)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my left orbital and the left side of my jaw are fairly asymmetrical. I am interested in possible left cheek implant, andleft jaw/chin implant. I would actually also like to build out the left side of my nose and frontal bone if possible and fix my eyebrows as they are different heights. Also if you have suggestions I would like to hear them. I saw two plastic surgeons already, both said they could not help me . They did not actually look at me for more than a couple of seconds before they said that though.

A: Thank you for sending your pictures and indicating your objectives. To  summarize your facial asymmetry concerns, I list the following items:

1) Left jawline asymmetry (based on the arrow in the drawing this is located at the prejowl area which is the junction of the back end of the chin and the body of the mandible

2) Left cheek deficiency

3) Left brow bone-nasal deficiency

4) Left eyebrow excessive elevation

I don't know if any of these are from prior facial injuries or just your natural facial development. But either way, I can make the following comments/treatment recommendations:

1) It is not possible to improve your eyebrow asymmetry by lowering the higher left side. There is not a procedure that can accomplish that movement. Eyebrows can be lifted but they can not really be lowered. It is certainly possible to do an endoscopic periosteal release of the supraorbital tissues and see of that will accomplich some lowering (and there is little to lose by so doing) but I can't guarantee if that would really be effective.

2) The medial brow bone and upper nasal deficiency (which is bone based) can be built up by the onlay of a material through an upper eyelid (blepharoplasty) incision. While a wide variety of materials exist, I would opt for either an hydroxyapatite cement or a mersilene mesh onlay.

3) The cheek bone deficiency could be augmented by the use of a cheek implant placed through an intraoral incision.

4) The jawline deficiency (unless I am misinterpreting what your concerns are) appears to be a 'spot' area along the left jawline. I would build up that area with a mersilene mesh onlay to fill in the prejowl deficiency through an intraoral approach.

The three select facial skeletal deficiences (jawline, cheek and left brow-nasal) could be assessed in exact anatomic detail and custom implants made off of a 3-D skull model, but I don't think we have to go to that extent to get a good result. It may be ideal but I don't consider it absolutely necessary in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have quite a big cleft/dimple in my chin and I 100% want to get rid of it. I just wanted to know how much this procedure will cost and is it straight forward. Any advice would be hugely appreciated. Thanks 

A: Chin dimples and chin clefts have anatomical differnces but they both pose the same problem, getting rid of them 100% is not easily achieved particularly when they are ‘big’. The simplest and most straightforward method is by fat injections. A temporary elimination can be done by synthetic fillers. Fat injections offer the most straightforward approach for not overly deep chin dimples and clefts and are part of the treatment strategy when chin dimples and clefts are very deep. I would need to see some pictures of your chin to determine what is the best approach.

A chin cleft is an actual separation (defect) of the mentalis muscle with subcutaneous fat deficiency. In some cases they may even be a cleft in the underlying chin bone. A chin dimple is an isolated subcutaneous fat deficiency in the chin pad with only minor or negligible muscle deficiency.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 22 year-old girl who has a dented scar in the middle of my forehead as big as a dime. It is circular so filler will not work. Can tissue expansion work to create a new forehead? Is it possible to combine it with forehead lowering surgery. I figured that the scar from the expansion will be in the scalp or new hairline. I can send you pictures of my scar if you’d like. I really need a doctor to help me as I am constantly hiding behind hair and hats.

A: A round scar in the forehead poses a challenge unless it is very small and can be elliptically excised with a very small scar. But a round scar the size of a dime just about anywhere on the forehead is not an easy problem to improve, particularly if it right in the middle of the forehead. While it can elliptically excised, the length of the scar in the middle of a young woman’s forehead would not be a good trade-off and may actually even be worse. It is true that the forehead skin could be expanded and then the scar excised but that is a lot of effort to still end up with a visible scar even if its length is a little smaller and not ending up quite as wide. I don’t view tissue expansion as a viable option either.

I would recommend one of two potential approaches. The first is staged serial excision. This is in effect a ‘poor man’s’ tissue expansion. Do an initial scar excision that stays inside the boundaries of the round scar. Let it heal for 6 months and then come back and do it again. It may even require a third time excision but the goal is to eventually have a linear scar that is not much bigger than the diameter of the initial scar and be a fine line that is not indented. The other option is to try and fill it with either a fat injection or a dermal-fat graft. In essence, try to improve the contour but do not make any more scar that what you already have. Whether either of these is reasonable would depend on what the scar looks like. For this reason seeing a picture of it would be very helpful.

There is also the possibility that no method is really worthwhile for this depressed circular forehead scar and it may be left alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking into orthognathic surgery as I have a receding chin and asymmetrical jaw. I was wondering if this procedure helps shorten the length of the face? Also does it have any type of effect on the cheekbones? I have flat cheekbones and was wondering if this surgery would have any type of affect on them.

A: Depending upon the type of orthognathic surgery done and the bony movements, it may well improve jaw asymmetry and a shorter chin, although often a separate chin osteotomy needs to be combined with it. But it would be uncommon that orthognathic surgery will shorten the vertical length of the face. It may make no significant vertical change or may even lengthen it but vertical shortening will only occur if the maxilla is being impacted as part of the treatment plan. What is for absolute certainty is that the cheek bones will not be affected in any way, positive or negatively, with orthognathic surgery. The horizontal bony cut at the LeFort 1 level goes below the cheek bones just above the roots of the upper teeth. Cheek augmentation can be achieved at the time of orthognathic surgery, however, by the simultaneous placement of cheek implants above the level of the osteotomy cut on the flatter cheek prominence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a shotgun injury to my face over two years ago with a lot of remaining metal pellets around my face. I had some fractures of the cheek bone and eye and these were initially fixed with metal plates and screws. I got an infection after surgery around my eyelid incision and cheek which then needed to be drained. Afterwards my eyelid was pulling down. I have a lot of residual problems from this injury and the subsequent surgery to fix it including a lot of pain from the plates, a down pulled eyelid and the movement of the metal pellets that are retained is quite uncomfortable. I am going to have another reconstructive surgery done. The doctor plans to use implants to replace the titanium mesh to build my orbital floor. He also wants to use an implant for my cheek as I have lost part of my cheek bone. A scar revision for my cheek will be done too. He says all this can be achieved in one surgery. What do you think about this treatment plan? 

A: While much can be accomplished in another reconstructive surgery, it is important to do three things during your surgery. First, all currently indwelling hardare that is loose or easily palpable should be removed. This also applied to anmy remaining metal pellets in our face that can be identifed as easily accessible, palpable and known to be painful. Second the anatomy of the displaced bones should be fully exposed so the floor of the orbit and the cheek bone can be seen as to how much displacement they have. The debate is to whether these defects should be reconstructed with facial implants or bone grafts. Given your history of infection, I would be concerned about any implant that has exposure to your maxillary sinus. For this reason, I would lean towards using bone grafts when possible. Lastly, the lower eyelid ectropion can be released and resuspended. All of these procedures could be and should be done in a single operative session.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an untreated zygomatic fracture after trauma from 3.5 years ago. My cheek is about 2mm flatter than the other side. The position of the eye looks normal and I have very little compression of the infraorbtial nerve, so little that I think it’s still “fully alive”. The feeling of the V2 nerve area its completely ok with maybe a little paresthesia when I push on it. I am now in the process of doing  a CT and EMG of the nerve. As soon as i will get the results of the tests I'm going to consider surgery. What about the infraorbital nerve issue during surgery? Possibility of permanent damage? Is it better to have 90% of feeling without surgery than 0-10% after operation?

A: If I interpret your condition properly you have minimal displacement of the zygoma and 90% to 95% normal function of the infraorbital nerve. (minimal nerve compression)  With these minimal ‘problems’ I would question why undergo any surgery at all for these minor potential improvements. But if you were to do something, the treatment should match the magnitude of the problem. The zygomatic deficiency would be treated with a very small cheek implant not an osteotomy. The nerve would be released from around the foramen by a small foraminotomy. These two procedures have little risk of worsening the problems while providing the potential for correction of the aesthetic and neurological sequelae from your initial injury.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, can I get a facelift with a laser? A doctor I was seeing for a skin condition said that he could get me some lifting of my jowls with a laser. My jowls are beginning to sag and it would be nice to have a straight jawline again. What is your experience with the success of skin tightening with a laser?

A: There are many products and devices out there that lay claim to being able to “lift the face”. All of them offer the same fundamental appeals, minimal recovery and lower cost than a real facelift, which is understandably attractive. The laser is one of the most sophisticated of these non-surgical devices and its high-tech nature makes it seem like it should be able to accomplish that facial effect. While lasers have a very valuable role in facial rejuvenation through its skin resurfacing effects, improving loose and saggy skin is not one of them. Lasers, particularly the more recent development of fractional laser technologies, can smooth out the skin, reduce wrinkles, and provide a mild amount of skin tightening. Ask any patient who has had full face laser resurfacing and they will tell you that their face definitely feels and looks tighter. But this laser skin tightening effect should not be confused with what most people want to accomplish when they use the term ‘facelifting’. Its effects are not great enough  to lift and smooth out sagging jowls and loose neck skin. Lasers have their greatest skin tightening effects when they are combined with any of the various forms of facelifts available today. In your case, having a small jowl lift combined with full or partial facial laser resurfacing can produce some really significant improvements that will persist for years. Just don’t try and achieve that effect with a laser treatment alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had two chin implants that had various problems so I opted for sliding genioplasty. For this surgery my surgeon drawn some sketches on my x-ray tracing which added 6 mm. I knew my prior implants didn't give vertical length and 6 mm looked fine and he explained about soft tissue draping that it would add some fullness too. I showed him examples of the chin I would like to have. And he said it’s possible. But now I am utterly frustrated as even after talking things through and showing him what I wanted I am stuck with how my chin looked like with an implant with very little added vertical length. Please let me know your thoughts. Should I ask for revision? When I told him my concerns, he said not more than 5-6 mm is possible with sliding genioplasty because that is what the metal plate allows. 

A: My only comments are:

The step chin osteotomy plates go out to 10 to 12 mms, depending upon the manufacturer. I am not familiar with a 6mm advancement limitation by the fixation device. In some patients, there may be a bone thickness limitation for the amount of forward movement that can be achieved. 

When measuring the chin bone for advancement by a sliding genioplasty, the soft tissue does not add any fullness. It moves in a 1:1 relationship with the bone. Therefore, for example, if you want the soft tissue chin point to move 10mms to get a desired look then move the bone 10mms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, why does electronic stimulus or surgery eliminate the headache associated with migraines? I noticed when I apply pressure with my forefinger the headache is relieved. Why is that accomplished? Is there any guaranteed method to relieve headaches caused from supraorbital nerve dysfunction?

A: Compressing the area of the focal headache is known to provide some temporary relief and many people do it to try and get some very temporary headache reduction. It is not known precisely why this works although the most logical explanation is similar to what happens when you burn your fingers or hit your thumbs with a hammer…you instinctively shake your the hand which does help to relieve some of the pain. This works because other sensory fibers than those carrying pain in the nerve supplying the area are stimulated. (such as pressure and movement sensations) This cuts the number of nerve fibers that can carry pain, thus one feels less pain. (competitive stimulation so to speak) Otherwise, there are no guaranteed methods for migraine headache relief. In properly selected patients surgical decompression has a high rate of success in the majority of patients with reduced frequency and duration of headaches that is sustained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, a little over a year ago I had contacted you about possibly doing a jaw implant procedure. I decided to try an injectable filler (Radiesse) first for a year before moving forward with any permanent surgery. I now think I would like to move forward with an actual implant(s). I have some asymmetry between my left and right side, with the right side being the “weaker” side. I could use a slightly stronger jawline overall, but I see my main area where I want improvement being my right side. I am still unsure if I want to do both sides for a wider jawline and symmetry or just the right side. Can you comment on the swelling time frame and when I can expect to look 100% again?  And if I do decide to do surgery will a CT scan be part of the process?  Thank you very much

A: When it comes to fixing slight asymmetries on just one side of the face (in a young male patient), I would caution you that it is very hard to achieve using standard off-the-shelf jaw angle implants. There will invariably be improvement but asymmetry will usually persist/develop for other reasons. It is virtually impossible to get a perfect match to the other side by just guessing with stock implants. When it comes to asymmetries like yours and only one side wants to be done, I would urge a patient to get a custom implant made on matching the anatomy from the other side. That is the best way to not develop another 'problem' after the surgery. Doing just one side with a stock implant is fine but you would have to accept that it will not be perfectly symmetric so such an approach is only good for the patient who is willing to accept the imperfections of the procedure.

To put it bluntly, the recovery from jaw angle implant surgery is significant. It is not that it is so terrible it is just that it will be much longer that you envision it and most men are not really prepared for the duration until they look more normal. (socially acceptable) If you are using the criteria of 100%, meaning the final result then that is 3 months. If you are looking at when do I look reasonably normal (50% to 75% of the swelling is gone) then I would look at three weeks. Other than some early jaw stiffness and decreased oral opening, the recovery is largely social. (how do I look?)

Lastly, a CT scan is only part of the process if custom implants are being made.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have attached a picture of myself so you can see my chin. I do have a “ball” on the chin but I do not know what causes that. Each surgeon seems to have a different opinion about it. One surgeon told me it is caused by soft tissue and the mentalis muscle and that he can spread out the mentalis muscle and remove soft tissue to flatten the ball a little bit. But that worries me as I already have some dimples when I smile. I am afraid it will show irregularities on my chin (bumps, dips). How is it possible to know if it is the bone or the muscle and soft tissue causing this? Another surgeon said it would be best to shave the ball a bit (he thinks it’s caused by the bone); what are my options? and the risks? Thank you so much.

A: The one thing that I can tell you for certain is the ball on the end of your chin is all soft tissue and not bone. That is the confluence of the paired mentalis muscle and subcutaneous fat in the midline of the soft tissue of the chin. It is never a bony-based problem. The only way to reduce it is by intraoral soft tissue excision, there is no such procedure as ‘spreading out’ the mentalis muscle. You are correct in assuming that any deflation of the ball does pose risks of overlying soft tissue irregularities, particularly if fat is removed as this lies closest to the underside of the skin. If some of the deeper muscle is removed and swen down to the bone, this is the safest method of reducing its promienence and avoiding any obvious statis or increased dynamic chin dimpling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just wanted to have a jawline. As you see from my pictures there really is no jawine. All I can see is that  big neck and I always wanted too be able to wear a hat but when I do put a hat on all you see is my turkey neck. Man I want to someday to comfortably put a hat on. There is nothing worse than two chins but it could be worseso I just  accepted it. I just finished working out after work, anything to try and prevent a third chin. I really am gratefulyou took the time to review my case.

A: Thank for sending the good profile pictures. I can clearly see your concerns and they are based on the issues of having some bony chin deficiency (with a ball of soft tissue on the end of it), a high hyoid bone and a relatively short neck. These three factors give you the jawline-neck appearance that you have and do make it a challenging problem.  Necks like yours are not easy to improve in males. There is not just one procedure that will correct all three contributing anatomic issues so a dual approach has to be used. I would advance the chin with a sliding genioplasty to lengthen the jawline, pull some of the neck muscles forward with it and increase the chin prominence. That would also stretch out the redundant soft tissues of the chin over the advanced bone. At the same time, I  would then perform a submentoplasty procedure designed to remove neck fat and tighten up the neck muscles from below to make a better neck angle. This combination (sliding genioplasty/submentoplasty) would make improvements as demonstrated in the attached computer imaging. This will not completely get rid of the neck skin roll that you are making when you tilt your head down but that would require a formal necklift which, may not only be  further than you want to go at this point, but I would await to see your level of satisfaction with these other more ‘simpler’ procedures first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had previously two chin implants which failed to give the length I desired. So I had an sliding genioplasty two months back with implant removal. As the swelling has gone down I look almost same as I did with implant. My surgeon said he advanced my chin 6 mm downwards and 5 mm horizontally. Is it the maximum advancement possible with sliding genioplasty? Your wise thoughts will be very much appreciated.

A: I have several thoughts about your chin surgery history and your question. Did you and your surgeon have a good understanding before surgery using computer imaging as to your desired chin goals? Changing the chin is one of the most predictable of all aesthetic structural facial procedures as the bone/implant change is 1:1 with the overlying soft tissues. It seems very pecular to me that you could have had three chin surgeries, none of them with large chin changes, and still end up inadequate. The bony genioplasty movement of 5mms horizontally is not very significant and, regardless of whatever size chin implant was in before, I am not surprised that you look no different now. You essentially swapped out the change provided by an implant for that of an osteotomy but no more. (other than some vertical increase) When one trades out an implant for an osteotomy it is because the osteotomy can make dimensional changes that an implant can  not. While chin implants are not capable of providing more than a few millimeters of vertical height increase, they are capable of 9 to 10mms of horizontal lengthening. The amount that a bony chin can be advanced is based on the thickness of the bone but in most cases the amount of lengthening can be 10 to 12mms as the back edge of the downfractured chin segment touches the front edge of the intact upper chin bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a pointy ridge of bone running down the center on the top of my head. Therefore when you look at me face on instead of the normal curve or round shape it looks more of a point. As I have to keep my hair short this makes my head look very odd. I didn’t think anything could be done until I just saw your before and after photos which has given me a little bit of hope. I hope you can help and look forward to your reply.

A: It sounds like you have a very classic sagittal ridge from front to back, a microform of sagittal craniosynotosis if you will. The midline ridge represents either an isolated thickening of the original sagittal suture or a midline ridge combined with some narrowing in the parasagittal out towards the temporal line. In most cases, it is the combination of the two that creates the look. Improvement in shape can be done by skull reshaping consisting of either sagittal ridge reduction alone or combined with a some build-up to the sides to make for a less high and more rounded skull shape. Very visible improvement in your skull shape is possible…provided you can accept a scalp scar to do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year-old male and I would like a well-defined jawline. I have attached some pictures for your thoughts.

A: Thank you for your inquiry. When it comes to improving the 'jawline' that could mean various things to different people. Fundamentally it comes down to whether one wants the front of their jawline (chin), the back of their jawline (jaw angles) or both improved. Those distinctions are obviously important as they involve different procedures.

In looking at your photos, an obvious horizontal chin deficiency exists. That could be significantly improved by either a chin implant or a sliding genioplasty. There are advantages and disadvantages to either approach and, based on what I see so far, I would lean towards a sliding genioplasty which would advance your chin up to 12mms but would also narrow it a bit in the frontal view which may be aesthetically advantageous for you. I have attached some prediction imaging of that potential result from the side view. It is not clear, based on just one photo, that augmentation of your jaw angles would help improve your jawline. I have done some imaging on this grainy frntal photo but it is questionably helpful. Better photos would ultimately be needed to clarify this issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty in 2010 and I feel that it looks short for my face, nostrils not the same shape or size, alar base too round and wide, nostrils are flared. Nose is upturned and too short for my face. I feel my upper lip has too much space from lip to nose. Would like a softer more feminine appearance.

A: Thank you for sharing your story and photos. I obviously do not know what your nose looked like to start with and exactly what was done to your nose. It would be extremely helpful to see photos and the original operative record from your 2010 rhinoplasty. What types of grafts were harvested (if any), where they may have been placed, and what is left of the original cartilaginous structures will all play a part in what needs to be done. Secondary rhinoplasty surgery is usually much more difficult because of scar, distorted structures and sometimes depletion of easily available cartilage graft harvests.

But that important issue aside, your nose is short with wide nostrils. The tip lacks projection, the columella is short and upturned and the dorsum is low. Such a nasal shape is very characteristic of many ethnic rhinoplasties. (as said by a Caucasian plastic surgeon) In changing your nose to your desired goals, it is a matter of the degree of change. It is an issue of either tip derotation and nostril narrowing or that combined with dorsal augmentation. That aesthetic difference is important as that would determine the type and amount of cartilage grafting that will be needed. But either way cartilage grafts would be needed and most likely that means costal or rib graft harvesting to get the amount of straight pieces of graft needed, particularly if dorsal augmentation is going to be done.

As for the lip lift, I don’t see the benefit in your case. Your upper lip skin is already at a good length with substantial upper lip vermilion show. I think you perceive your upper lips as short, as least partly because of your short and up turned nose. While I doubt its benefits to you, I would at least wait until the nose is done and see what you think about your lip then. An open rhinoplasty and lip lift has to be performed separately anyway due to blood supply concerns of the intervening columellar skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to get the prominence of the back of my head reduced but I have previously had hair transplants done over six years ago. Will this prevent me from having the skull reduction procedure?

A: That is a very good question. I will assume that you have a linear occipital harvest scar now. about in the middle or lower end of the back of the head. This would be the typical location for a traditional hair transplant harvest siteIf one was trying to do an augmentation, having had an occipital harvest site would be problematic and would preclude it. But for an occipital reduction it does not. Depending upon the exact scar location, it may be able to be used for the skull reshaping reduction. and its presence would be fortuitous.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year-old mother of three children and I just finished breast feeding my last child. As you might imagine, this has taken a toll on my breasts and I would like to get back to feeling like a sexy women again as opposed to a women whose chest looks like she has had the life sucked out of it. How soon after breast feeding can I get a boob job? Thank you for your advice.

A: This is one of the top five questions that I get in regards to breast augmentation. When one is done having children, the change in one’s breast appearance can be dramatic and very discouraging. This often prompts the consideration for getting breast implants and can make a dramatic in their appearance and one’s self-image.  The minimal time to consider breast augmentation is based on two issues; are you done actively lactating (some women may still be to create milk long after they are finished with active breast feeding) and have your breasts shrunken down to a stable size. When you put these two factors together, the answer will change for each individual woman. For some it may be as soon as 6 to 8 weeks after breast feeding, for others it may be 3 to 6 months until it is a good time for getting their breast implants placed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible for you to reshape my skull with an implant or permanent injectable filler? My head is flat at the crown and from most angles looks like I'm missing a part of my head. Instead of the typical incline from the brow to crown, mine does  the opposite. It serves to elongate my lower face, throwing my facial proportions off balance. And as my hair is quite fine and rather volume-less, the way my hair frames my face, particularly when it's loose, is most unflattering.This is by far my main body issue concern and upsets me constantly. I can't seem to get past the frustration and I know it's in part because I can't hide this inside baggy clothes or some constant disguise. If I could ignore it, I'm sure I could forget it. But I can't ignore it when I have to look in the mirror each morning and do my hair. And then go out into the world feeling horrid.  Here are some pics of imaged results that are my ideal. Would this be possible to achieve?

A: What your concerns are and are demonstrating is occipital augmentation and is the most common location for skull augmentation. Flatness at the back of the head is the number one cosmetic skull concern that I see and treat. The important question for every patient is how much skull augmentation can be achieved and is what is possible worth it for the surgical effort for the patient? What you are showing as your ideal result with computer imaging is exactly how I would have imaged it based on what I know is possible based on my own experience with this form of skull reshaping. That is a very realistic and expected result based on how much the scalp can expand to accommodate the expanded underlying bony contour.

Dr. Barry Eppley

Indianapolis, Indiana