Your Questions

Q: Dr. Eppley, I had jaw surgery over 20 years ago and am experiencing headaches and upper jaw movement. I saw a surgeon who took a c-scan and said there is no bone holding jaw in place just scar tissue. I am looking for consultation. I would like to find some one who has experience in this procedure.

A: Based on your description of upper jaw surgery, I am going to assume that this means you originally had a LeFort 1 osteotomy. This would be a standard horizontal maxillary osteotomy done right above the tooth roots. If done over two decades ago, it may likely have been secured at the time of surgery with stainless steel wires rather than the more common plates and screws used from about 1990 on.

To have upper jaw movement at this point, you would have to have a partial or complete non-union of the osteotomy site which is hard to imagine at this point in time after your surgery. But a CT scan would show the bony anatomy across the osteotomy site and should have been completely healed in with bone even at 6 to 12 months after surgery. So if the surgeon sees that now, I would conclude that it is a real phenomenon as unusual as it is. This should be evident clinically by seeing if the maxilla (upper jaw) has much movement in it.

The question now is what to do about it, particularly given your symptoms. If your occlusion (bite) is good, I would recommend a debridement of the osteotomy line, placements of plates and screws and bone grafting to provide stability and get at elast a partial union across the osteotomy site.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my face is very unbalanced as my chin is very short. This also makes my neck look fat even though I am at a good body weight. I have attached some pictures for you to tell me what you can do for my really short chin. It looks like the lower part of my face is just missing.

A: Here is a side view prediction based on the combination of a chin bony advancement (sliding genioplasty) combined with an implant. Your horizontal chin deficiency exceeds 15mms which puts you well beyond what any conventional chin implant can do. A chin osteotomy will advance you up to 12mms, which is better, but also not ideal. Therefore, in cases like yours I will put an implant in front of the advanced chin bone as well that will add another 5mms to the projection. The addition of the implant also has the advantage of its extended lateral wings which will fill out the sides, making the chin a little more square. That is an advantage for a male who benefits by a more square chin anyway. In addition, your thicker neck tissues would simultaneously benefit by liposuction under the advanced chin area to try and thin that out a little but.

The combination of a chin osteotomy and implant combined with neck liposuction can make some significant changes as the imaging suggests. This type of ‘extreme chin augmentation’ is necessary to get the best result in larger male chin deficiences like yours.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to get a forehead burr hole filled from a previous craniotomy that I had done. If you used hydroxyapatite (HA) material, would the HA be applied directly on the burr hole coming to direct contact with the dura? Would a mesh and screws be also used?

In addition, I want to get my brow ridges built up as they are a little flat for a guy. Do you favor having the the eyebrow implants custom-made or would you make them during the surgery? Can’t HA cause a necrosis of the surrounding tissue during curing? What would be the advantage of using HA for the eyebrow ridge implant over medpor, PEET, or any other existing material?

A: In answer to your questions:

1) When reconstructing/filling in burr holes, it is first necessary to dissect the soft tissue/scar from both around the hole and the bone edges to identify clearly the bony margins. This scar tissue directly lies over the dura so the material does not lie in direct contact to the dura. Even if it did, however, this would be of no consequence or concern. Because they can be some ballooning of the scar/dura into the burrhole, it can occasionally be necessary to push this tissue down so the bone edges of the hole are exposed. This is done with a small piece of titanium mesh (no screws) whose edges grip the bone to keep it in place.

2) I am not sure where you get the impression that any cranioplasty material, HA or even PMMA, can cause any tissue necrosis during curing. HA is a completely cold curing material that has no exothermic reaction during setting. Even PMMA, which does have an exothermic reaction during curing, is very mild and never exceeds 110 degrees F. The actual temperature at which tissue damage could occur is at 142 degrees F and above. Decades ago the original PMMAs had high cure temperatures but those versions no longer exist. This has never been an issues with HAs and, when they were introduced in the mid 1990s, that was one of their big advantages over PMMA, a neutral set temperature.

Brow ride augmentation can be done nearly 10 different ways, largely depending on what material is being used. In the right hands, they all can be effectively done from an aesthetic standpoint. What one has to look at then is the material’s biology, what is the process to place them and the cost to do it. The most biologically compatible material is HA because it is composed of the inorganic content of bone, calcium phosphate. This bone will bond directly to it and may even get a small amount of bone ingrowth. It is also the easiest to place and mold into a desired shape. All other typical synthetic facial implant materials, such as silicone, Medpor and Gore-tex, must be hand carved at the time of surgery from a block of material. While this is very doable, it adds to surgical time and the they must be screwed into place for stability. Materials such as HTR and PEET must be made beforehand off of a 3-D skeletal model. Between the costs of the model and the fabrication of the implants, this could easily add up to $10,000 in cost to the surgery. That would be acceptable if there was some overwhelming biologic advantage to the these materials, but there is not.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had orthognathic surgery of my upper jaw 2 years ago. My upper maxilla was impacted (5mm), advanced (5mm) and moved to the right (2mm) with a Lefort and lateral segmentation of my upper jaw. I got cheek implants, a mentoplasty without implants and jaw angle implants (porex) in standard size. I want my jaw angle implants removed and replaced as I am not happy with the results. My surgeon did a second surgery to try to file the existing implants and create more symmetry (one side is longer than the other with the implants) but even then the result is not good and the only thing to do is to remove the porex implants and replace with custom made. In addition to asymmetry I find that there is not a nice jaw line between the implant and my chin (not continuous line) which create a strange visual effect (it feels that the jaw implant should have continue to meet with my chin). To me is very important that the surgeon that is going to perform the surgery is both knowledgble and has a ‘cosmetic’ eye. I wish to have advice of how difficult this type of corrective procedures are.

A: I am not surprised that revision of porex jaw angle implants did not improve the problem. They are virtually impossible to merely ‘file’ in place due to their harder plastic structure. In addition, it is very common to have some disruption of the jawline between the chin implant and the jaw angle implants, particularly if the jaw angle implants created any vertical lengthening.

While I don’t have the advantage of knowing what your face looks like and an appreciation of skeletal anatomy, I can make some general comments. Removal of porex jaw angle implants is difficult but far from impossible. I have removed such implants numerous times. The question is how best to replace them. There is obviously a reason you had them placed initially whether it was for angle definition, widening or vertical lengthening. Such desired changes would be important to know. It does not appear that standard jaw angle implants may suffice. Custom jaw angle or jawline implants are made off of a 3-D skeletal model. They can be made in any shape and size based on needs and are fabricated out of silicone not porex. Placing the new jaw angle implants is no more difficult than the insertion of the initial jaw angle implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to know if it is possible to have two procedures done at the same time. I want my ears tucked and a mini face lift or a limited lift done. Thank you.

A: Both an ear pinning (otoplasty) and a facelift can be done at the same time under certain cirucmstances. The key to whether these can be performed together is what type of otoplasty and what type of facelift is being planned. In a traditional full facelift there is an incision along the back crease of the ear. This would be lower than the incision traditionally used for an otoplasty which is higher up on the back of the ear. Many plastic surgeons may justifiably feel uncomfortable having two paralleling incisions along the back of the ear due to intervening skin survival concerns. So an otoplasty may not be recommended at the same as a full facelift. In a limited or mini-facelift, the incision on the back of the ear is more limited or not used at all. So an otoplasty can always be performed at the same time as a mini-facelift.

When an otoplasty is done with a facelift there will be some greater and more persistent swelling of the ear but this is an eventual self-solving issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for the longest time I have had my heart set on rhinoplasty but didn’t want to go through a big operation. However I have recently learned that a much less complicated procedure can be preformed that involves reshaping of the nasal tip. (tip-plasty) I was wondering whether or not you feel as though tip plasty would be to my benefit or if you feel as though I should undergo full rhinoplasty. The only aspect of my nose that I have ever had an issue with is that the tip appears too bulbous from the front and 3/4 side view. I also feel as though it protrudes slightly too far from my face. I tried taking some high definition photos, but they would not upload so I had to use webcam photos. the frontal photo is extremely bright however it was the only way to show the definition of my nose from the front.

A: Rhinoplasty is very much like many other aesthetic facial operations, they are numerous versions in magnitude that are used based on the problem being treated. Simplistically, rhinoplasty can be thought of as either a full rhinoplasty or a tip rhinoplasty. The difference between the two is that a full rhinoplasty includes significant changes in the bridge of the nose and will always involve osteotomies or breaking of the nasal bones. Tip rhinoplasty usually does not include much internal work such as septal straightening and turbinate reduction. While there are many cross-overs between these two basic rhinoplasties, depending on patient need and desires, this is a very basic way to view them. More tip rhinoplasties are done in revisional surgery than in primary rhinoplasty.

While your tip is large, I would agree that the top portion of your nose looks in better proportion. I think that an isolated tip rhinoplasty would be of great benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m honored that a surgeon of your stature and extensive experience in reconstructive/cosmetic surgery has replied to my posting. My understanding was that “Kryptonite” was the best material to be used for a cranial implant. I also have a burr hole just above one of my eyebrows and I believed “Kryptonite” would be suitable for both the supraorbital implants an the burr hole plug. As you know HA is brittle. Both HA and PMMA lack the osteo-conductivity of Kryptonite so what is the problem with Kryptonite will it be back on the market at some point or is it off the market for good? I hate the idea of having too loose foreign bodies floating on my forehead. Could enough bone be taken from my hip to carve two implants for my eyebrows and the burr hole?  Theres also a crack that extends downwards from the burr hole. What would you put on this crack.? Bone shavings? If access to the burr hole form the endoscopic brow lift of the upper blepharoplasty isn’t good enough, would it b possible to mke an incision in the eyebrow that will be covered by hair? As you can imagine I would like to avoid a coronal incision at all costs although I had one before and didn’t have any problems afterwards. Would this surgery need to performed by a plastic surgeon like yourself an oculoplastic surgeon, or a maxilofacial surgeon? You are not a maxilofacial surgeon, correct?
I thank you in advance for your help. 

A: I believe you have some basic misunderstandings about the various bone cements. Kryptonite is no more osteoconductive or has higher biomechanical properties than its ‘cousins’, the hydroxyapatite cements. Kryptonite is composed of calcium carbonate while hydroxyapatites are composed of calcium phosphates, thus they are very similar. They are not brittle when applied to the bone and do not become loose. I have used them in many patients for cranial defects and for forehead/skull brow augmentation and have never seen any issues with fracture or fragmentation. That is a theoretical concern that has little clinical relevance.

While Kryptonite had the one feature of some degree of injectability, it otherwise has no other biologic or mechanical advantages. It is no longer available, to the best of my knowledge, because the company voluntarily withdrew it from the market for reasons they did not disclose. I would have no idea if it would ever be back on the market. But your case is not a good case for injection anyway due to your prior surgeries and scar.

The best solution to your brow/forehead issues is to re-open your coronal scar, fill the burr hole and cracks with hydroxyapatite cement and build up the brows also with hydroxypatite cement. This would provide the good access to do the procedure properly. This can not be done through an endoscopic approach nor would the scars through the eyebrows turn out very well. I understand your desire to avoid the coronal incision but that can not be avoided and get a good smooth bony result in the desired shape and fill.

Lastly, I am board-certified in both plastic and reconstructive surgery as well as oral and maxillofacial surgeon with a lot of craniofacial experience since you asked.

Dr. Barry Eppley

Indiana;polis, Indiana

Q: Dr. Eppley, I was wondering if you could help fix my forehead; it’s been through a lot. When I was a toddler, I ran face-first into a wall, and since then, I’ve had a bump on the right side of my forehead. A year ago, it started to seem more prominent, and it wasn’t my imagination, because family pointed it out too, and sometimes the bump felt sore. I went to see a dermatologist who referred me to a facial plastic surgeon who injected the bump with steroids. This only left a dent around the bump, which he filled with Juvaderm, which has since worn off. Now I have a dent and a bump, and they each make the other look more prominent. It’s mostly noticeable when I move my forehead, which is a lot, because I’m pretty facially expressive. What should I do? I’d be happy to send pictures. Thanks!

A: Please send me some pictures of your forehead issue for my assessment. With your history, that bump is bone and not scar. That is the typical reaction to forehead trauma, a subperiosteal bleed that is a stimulus for bone formation. I would not have expected steroids to do anything. Most likely this would require bone reduction for elimination. The dent issue is soft tissue atrophy from the steroids which may need to be filled out with a dermal graft ‘ring’ around the area of bone reduction to get the most even forehead contour.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a birthmark that I tried to get removed. It was treated with a laser with no results. It is brown-colored and is a patch over the left side of my stomach. I have had it since I was born and it has grown in size as I have grown. I have attached a picture of it for you to see. What type of treatment should I get to remove it. Also, if it can’t be removed can it be tattooed over?

A: What you have is a classic cafe-au-lait birthmark that is virtually impossible to remove. The reason is that the brown pigment goes all the way through the skin, so no ‘pigment reduction’ laser/treatment will work. The brown color also will no respond to being lightened like age spots do with pulsed light therapies.  One option may be fractional laser… test patch an area to see the response.What type of laser treatment was done before? I doubt if it was fractional. Its an option but there are no good treatments for cafe-au-lait spot removal…short of excising it and trading that off for a scar…which I am not sure is a good trade-off. Also, you can not tattoo over it and match the surrounding skin. Besides an impossibility to match the surrounding normal skin pigmentation, it is not practical to make a darker skin color lighter by tattooing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know the sizes of butt implants? how big is the largest one and how many inches thick? and if it has liquid inside or if it has hard gel? Also can I dive to MO after couple days after surgery? Thank you.

A: Buttock implants come in a wide variety of sizes based on volume and base diameter. While buttock implants can range up in size to 550cc with 5 cms projection, there is little reason to put more than 300cc to 350cc in any patient. This produces a surprising amount of buttock enlargement  for most patients. This is about the maximal size that can be placed through a 7cm intergluteal crease incision and fit into the intramusular pocket. Trying to place anything bigger is an invitation to complications. While larger buttock implants can be placed above the muscle, this is not a technique that I use as it has a high complication rate such as implant displacement and fluid collections.

Buttocks implants are composed of a very soft silicone gel (not liquid) which feels like a compressible sponge.

Realistically, you would not be comfortable to sit on your buttocks and drive two days after surgery, even if you were just driving around the block. All patients will need someone to drive them home no matter where they live.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery one month ago. While I have fairly large boobs to begin with I am disappointed with what I see so far. I see very little difference. I thought all my chest fat was going to be removed and the saggy skin tightened. I expected a flat chest but that is not what I have. What do I do now?

A: While I have no idea what you looked like before and now after surgery, your description leads me to give some general comments. As was likely discussed during your initial consultation, gynecomastias that have more significant mounds and hanging skin are difficult problems. In such cases the problem is the amount of extra skin that you have and not so much the fat which has likely been significantly reduced from your surgery. (you can not remove all fat from any body site anywhere so this is not a realistic concept) In these larger gynecomastias the choices are to place large scars across your chest to adequately remove the extra skin in a single operation or to limit the scars to around the nipples and see how much improvement can be obtained being restricted by this approach. Large scars that extend out from the nipples are not acceptable in men in my opinion and a choice you would regret later no matter how flat your chest became from that approach. Because of keeping the scars acceptable and to just around the nipples, the chances were likely that a second surgery would be needed for further skin reduction and the best result. Your gynecomastia problem is undoubtably a challenging one and one of the most difficult to treat without undue scarring. 

At this point, it is too early to yet judge the final result from your initial gynecomastia surgery. It takes up to three months for all swelling to go away and the tissues to maximally contract to see the final result. Whether it will signficantly improve or not is unknown but you must give it that amount of time. I would suggest that you go back to your surgeon three months after the procedure for further follow-up and discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an abdominal scar directly down the middle of my stomach which measures about 15 inches along with train tracks. I had exploratory surgery done decades ago. I would like to have it removed. It’s not that its ugly but I am tired of looking at it and I want it removed. It makes me insecure and I don’t think that Icould ever be in a relationship with this scar. Please help.

A: There are two concepts about your abdominal scar that important to understand. First, the idea of scar removal is not possible. No scar can be completely eradicated from visibility. Scars can be reduced and made less noticeable but completely normal skin contour and color can never be achieved. There are limitations as to what scar revision can do. Second, the width of the train track portion of the scar is important as this will determine how much of the scar can be excised in a single scar revision procedure. If the train tracks are too wide, a staged scar revision procedure may be needed. A picture of your scar will suffice to answer this question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants and fat grafting 3 weeks ago. The left implant is sitting too close to the lower eyelid and the end of the implant can be seen and felt at the end of the eye.  I have numbness in the upper lip and teeth. Is this normal? Implant was silicone and attached with screws.

A: Cheek implant asymmetry is not a rare problem. As the swelling subsides, usually about the three week time period after surgery, the position and symmetry of the implants becomes apparent. The most common form of cheek implant asymmetry is that one of the implants is sitting too high as evidenced by the lateral wing of the implant being palpable close to the corner of the eye. While it is something that you can tell now, the question is whether it is an aesthetic issue that ultimately you will want improved. If it is not seen or causes a visible lump, then it is an issue that most patients can live with. If the end of the implant is visible, you likely will wanted it adjusted for better symmetry. Intraoral placement of cheek implants almost always cause some temporary numbness of the infraorbital nerve with decreased feeling of the upper lip and teeth. This is a temporary issue, which is expected, and should resolve over the next month or so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you have any recommendations for topical ointments for my forehead laceration which was fixed about a month ago to help with the scar. Which are the best on the market? Do you have any knowledge or recommendations of using supplements like enzymes and vitamins to help reduce the scarring? I have read serraptase like in Vitalzym helps break up and remove scar tissue and was thinking of trying it. I’m trying to do anything I can to reduce it. Thanks very much for your time and advice!

A:I don’t think there are any magical scar creams, lotions or potions…despite how they are marketed and promoted. I also don’t think there are any vitamins and enzymes that help scarring either. While you can use any or all of them, they are as much psychotherapy as anything else for the typical non-problematic scar or surgical incision. This is not what most patients want to hear as understandably everyone wants to do the most they can for their scar. Time will create as much improvement as anything else. I think if it makes you feel better to use them then you should. There are other early scar treatments to consider, such as fractional laser resurfacing and broad band light therapies, that may have more profound effects than topically applied creams and ointments. This should not be construed to imply that the treatment of known problematic scars, or those that might potentially become so, will not respond well to the use of silicone gel sheeting and topical silicone gels and oils. But whether these are of benefit in many lacerations and wounds that might otherwise do well on their own is a matter of debate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in the process of correcting my jaw. I have had SARPE for my first phase. My main concern for the second phase of the surgery is to correct my flat under eye region. I would like implants to corrects this region of my face. I have a negative vector, flat upper cheeks, however I have moderate submalar projection. I have been told that my cheeks will fill out and the cheek fat of the submalar region will be pushed upward creating a fuller cheek effect, which I am seeking. I was also told, if I am still unsatisfied with my cheeks, it’s best to wait a year after orthognathic surgery to augment my cheeks. I have been reading that these procedures can be done at the same time and that orthognathic Lefort I osteotomy will not provide the same results as cheek implants/augmentation. I keep reading mixed reviews, Please help.

A: Let me answer your two questions directly and unequivocally.

1) A LeFort osteotomy, no matter how it is done, will not create a cheek augmentation effect. Based on where the bone cuts are and the how the bone is moved, this is simply not possible. Anyone that would suggest otherwise does not understand cheek augmentation.

2) Cheek implants can be done at the same time as a LeFort osteotomy. I have done it many times without any problems. It is as good combined procedure for the right patient. Just because someone had not done it before or is unwilling to do it does not mean it can not be done.

I hope this is helpful,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar from an accident that runs vertically on the middle of my forehead. The accident happened approximately one month ago. I am interested in hearing your thoughts about whether scar revision will significantly help as I am very self concious about it now.

A: As a general rule, one month after an injury would be way too early for scar revision for the vast majority of facial scars. The wound has barely healed and the scar is undoubtably very red due to the influx of blood vessels needed to help it heal. While being impatient is very understandable as it sits on a prominent facial area, patient is going to be urged in most circumstances.

That being said, there are two indications for early scar intervention. If the wound edges are horribly mismatched and it is apparent that no amount of healing time will improve its contour, then excising the scar and aligning the skin edges may be advantageous. The more common indications for early scar intervention is either fractional laser resurfacing and/or BBL. (broad band light therapy) These non-surgical approaches are done to help the redness of the scar fade sooner or to smooth out some fine edges early. Good wound approximation has to be present so there is no reason to suspect that scar excision would be needed later.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old man with a normal mandible angles but a slightly weak chin that has a little steeper angle then the rest of my jaw. Anyway I have been considering a square wrap-around or extend chin implant to slightly increase the width and moderately increase the forward projection of my chin But I am concerned that a chin implant will make my jaw angles appear greater so I was thinking a combination of a  chin implant with jaw angles might be right for me. So my question is generally speaking do you think that those people who undergo chin augmentation would benefit from jaw angle implants that increase the vertical height of the ramus decreasing the angle.(for me I think part of the reason my angles seem so square is because my chin is undersized and the angle is about 90 degrees but then after the groove increases to about normal dimensions) And then my second question do you have an photos that demonstrate the depression that is formed when off the shelf chin and jaw angle implants are used together?

A: There are no general statement that can be made about the influence of the chin on the appearance of the jaw angles. Each patient’s jawline and facial anatomy is unique and must be considered individually. The best way to answer your question is through computer imaging…change the chin without the jaw angles and see what it looks like. That is the best way to answer that question. You are correct in assuming that most standard chin and jaw angle implants do not meet in the ‘middle’ (body of the mandible) and, even if they do, these are thinnest and most tapered aspects of the two implants. Thus it is possible the jawline might not be perfectly straight from the chin back to the jaw angles and usually isn’t. But whether that occurs or not and is aesthetically significant depends on each patient’s jawline anatomy and the implants used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a depressed scar across almost the whole of my forehead, cheeks and chin. I have tried chemical peel and microdermabrasion, but all seem to burn that arena alone precisely. I think the tissue or skin in that area is pretty damaged and I would like to have it excised.

A: Based on our description of a long depressed facial scar, I am not surprised that microdermabrasion or chemical peels were ineffective for its improvement. Neither of these are appropriate treatment strategies for scar reduction. I am glad that you went through those though so you could prove to yourself that scar excision, radical as it may seemed initially, is usually the only effective treatment for a depressed scar. A depressed scar by definition has a thinner and more atrophic skin composition and a surface contour discrepancy to that of the adjacent normal skin. No treatments are really going to lower the shoulders of the edges of the normal skin to match the depressed scar and that would not be appropriate even it could. Removing the abnormal scar tissue and leveling the skin edges by bringing normal tissue together (surgical scar revision) is almost always a better approach…even if it is surgery and does take time to heal and for scar maturation to occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in neck liposuction, revision rhinoplasty, and cheek augmentation. I want to get rid of neck fat, define my jaw and neck line, straighten nose-one side of nose is bigger, and add volume in mid- and lower cheeks and under eyes. I have attached pictures for your review and assessment.

A: In looking at your pictures and your areas of interest, I can make the following comments/recommendations:

1) You jawline is ill-defined because your chin is both horizontally and vertically short. This makes your lower face look very deficient and creates a lack of any jawline definition. What you would ideally benefit from is a vertical-lengthening chin osteotomy which adds lower facial height and creates a more obvious jawline. This will also improve the appearance of a fuller/fatter neck although some submental liposuction done with the chin procedure would complement that improvement.

2) Your nose shows numerous secondary rhinoplasty issues. I do not have the benefit of knowing what you looked like before but I see issues relating to lack of upper dorsal height, tip asymmetry/thickness, nostril asymmetry and a deviated columella.

3) The need for volume in your cheeks and lower eyes is a bit perplexing to me. I see no benefit to lower eyelid volume augmentation. Perhaps with the chin lengthening, more volume in the lower cheeks (submalar implants) may be aesthetically beneficial to you. I have left those areas unimaged so you can see the other more important areas of facial change first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how big can custom facial implants be made? Can I get any size and shape that I want? I know you design a lot of facial implants for people having read your blogs. You talk about how it is better to be more conservative than extreme for many patients. Why can’t I just get any size facial implant I want?

A:  I have make these comments in my writings based on a lot of experience with men trying to design their own implants or providing me with very specific dimensions of what they want. I have seen too many cases where such outcomes have resulted in the need for revisional surgery because the outcome turned out to be different than they thought it would be based on its size and/or shape. I am always happy to accomodate patient requests and provide implant dimensions that one may desire, but I do so with the understanding that they then take responsibility for the outcome should the implant be too big or oversized. I make implant suggestions/recommendations based on my experience of seeing how a lot of facial implants turn out afterward as well as knowing the technical and tissue limitation difficulties that can come when trying to place large facial implants. While one can design anything on a 3-D model, that doesn’t always mean that the overlying soft tissues can equally accomodate its size. Custom implants must be designed with an appreciation of more than just how they sit or look on the facial bones.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck six  months ago and although I am happy with my lower abdomen I am not with my upper. It is still fairly thick and not as slim as the lower half. From the side view, the upper abdomen shows no difference unlike the lower. The only explanation that I can come up with is that my plastic surgeon refused to do liposuction of this area even though he did it to the sides of the tummy tuck. I can’t help but wonder if that had been done also it would look much better now. Can I get the upper abdominal area liposuctioned now and will it result in more loose skin afterwards?

A: Your question/concern of a tummy tuck result is a common one and one in which I review with every patient before surgery. Tummy tucks do their best work in the lower abdomen, where tissue is actually cut out, and offer more modest improvement in the upper abdomen. Your plastic surgeon was very prudent to not liposuction the upper abdomen during your tummy tuck as the risk of major healing problems can ensue at the central closure line . Thus many tummy tuck patients will have an upper abdominal fullness after their tummy tuck due to a persistently thick fat layer. This can be addressed after tummy tuck suction out extra fat and thin out its thickness. It will not cause any extra loose skin as that has been adequately tightened by the previous tummy tuck.

While we wish we could address the upper abdominal fat at the same time as the tummy tuck, it is wise to remember this basic motto in aesthetic surgery. It is far better to have two surgeries done safely than going for the perfect result and suffer a major wound healing complication which ca takes months to heal and leave a more devastating aesthetic problem than what one was initially trying to treat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large square chin implant that was placed 6 months ago that I am not happy with. As the swelling went away it became apparent quite quickly that it was not whaI wanted. The improvement is too small and it has little if any square definition from the front view. I have a 3-D jaw model done after the implant which I have sent to you. I am requesting a chin implant that is 19 mm thick and 3 inches wide from the front. I know that the implant  is going  to be fitted directly on the bone which means that it is going to curve around the chin to the side.That being said the squareness and the size of the implant is going to deviate from the criteria that I am trying to achieve because as the implant proceeds backward from the mid point of the chin it is going to take a different shape and size. Knowing that to maintain the squareness of the implant along the 3 inch width we need to increase the size of the implant as it proceeds backward from the midpoint of the chin. Please tell what you think.

A: I have received your 3-D model of your mandible with the existing chin implant you now have. The current implant you have appears to be a Style I square chin implant of 9mms horizontal projection. It is significantly asymmetric due to placement with the right wing of the implant being very high and right up against the mental nerve location. 

As to your dimension request for a new custom chin implant, this needs to be carefully thought over as 19mms of horizontal projection is significant and would be roughly twice of that you have now. The 3 inch squareness width, or 7.5 cms frontal width, is considerable and is about a 3.5 cm width increase over the implant you now have. It would be unusual to need more than 5 or 5.5 cms in most men to develop a square chin look from the front. With such a wide frontal square width, this necessitates the need for a wide width around the corner of the implant as it transitions back into the side of the jaw.

I would be careful to oversize the implant and it is easy to do. It may seem that these dimensions are needed/desired, but it can be surprising as to how these translate to one’s appearance once in place due to the overlying soft tissue thickness. You do not want to end up with a ‘Jay Leno’ chin afterwards which is way too big and result in the need for revisional surgery. 

I would suggest some smaller dimensions to the custom implant, more like 15mm in horizontal projection and 5.5 cms square chin width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed over 10 years ago which looked great. Then I lost a considerable amount of weight, over 50 lbs, and now look too sunken in. What is the best filler used to replace where buccal fat pads have been removed?

A: The answer to your question partially depends on how much volume is missing (how sunken in you are) and what method (surgical vs non-surgical) you want to pursue. But using the injectable filler criteria as your question posed, I will answer based on that one variable only. Because of the volume of the buccal fat pads (usually 5 to 10cc per side), the best replacement filler is fat injections. While the injection of fat is unpredictable, it offers an unlimited amount of volume for facial injections and it has the potential for some permanent volume retention. While there are many proponents for the various synthetic injectable fillers that are currently available, one has to recognize the cost of the volume needed per side based on the volume lost and that none are permanent. But if one had to go for a synthetic injectable filler, I would first use one of the longer-lasting hyaluronic acid fillers, like Perlane or Juvederm, to see if you like the effect. While there are longer-lasting fillers, such as Sculptra, Radiesse and Artecoll, they can be associated with higher risks of lumpiness and irregularities than the non-particulate hyaluronic acid-based injectable fillers when it comes to larger volume augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just need info on getting my belly button repaired. I don’t need a tummy tuck, literally just need my belly button put back after it “popped” during my pregnancy.

A: What has undoubtably happened is that you have developed an umbilical hernia as a result of your pregnancy. This has changed your belly button from an inne to an outie. The attachment of the belly button to the abdominal wall is an inherently weak point along the midline attachment of the vertically-oriented rectus muscles and their enveloping fascia. The enlarging fetus during pregnancy puts a lot of pressure directly behind the umbilicus. For some women this results in the area around the base of the umbilicus to separate. This results in the base of the belly button coming away from the abdominal wall and some intraperitoneal fat protruding outward. This push of tissue from underneath creates the change from an innie to an outie. You can probably push your outer in and feel a small hole underneath it. This can be repaired through an umbilicoplasty procedure, closing off the hole and re-attaching the umbilical stalk back down to the abdominal wall.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I need some help with an issue. I had an orbital floor fracture repair done a year ago with mesh implant. Since then I now have enophthalmos and nerve damage in my face. I want to know at this point is there anything you can do for me or suggest? PLEASE help me if you can I would greatly appreciate you! 

A: I will assume that you had an isolated orbital floor blow-out fracture. When that occurs, the supporting thin bony floor of the eye drops down. If significant enough (greater than a 1 cm floor defect) the eye will drop down. (enophthalmos) In addition, the large infraorbital nerve runs just under the orbital floor so it frequently gets trapped or pinched as the floor drops down. This is a sensory nerve (maxillary division of the trigeminal nerve) that supplies feeling to the cheek, lip and side of the nose. If injured or entrapped, patients may suffer long-term numbness or pain.

During an orbital floor repair, I always check for this nerve and make sure it is not entrapped in the blow-put fracture. Sometimes the nerve may be irreversibly injured, other times it may be entrapped and needs to be released. Reconstruction of the orbital floor can be done by a wide variety of synthetic implants or bone. There are proponents for all approaches and any of them can work with good surgical technique. The goal of orbital floor reconstruction is to prevent long-term dropping of the eye, known as enophthalmos, due to loss of support.

Since you have enophthalmos and infraorbital nerve dysesthesia, I suspect that further surgery may be beneficial by removal of the mesh implant, exploration and decompression of the nerve and a new floor reconstruction done. The first place to start, however, is with a good CT evaluation. I would get a 3-D CT scan of the involved orbit to first look at the anatomy. Based on that information, surgery can be planned appropriately.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting fat injections to my face as I have lost some volume in the cheek area as I have aged. As I read about fat injections it seems like there is some controversy as to how well they work or how long they last. I have read several doctors who claim if the procedure is done right the results are excellent with good long-term survival. How do I know if my doctor will do the fat injections the right way?

A: It doesn’t really matter what anyone claims about fat injections. They are unpredictable in terms of survival no matter how it is done and anyone that would use the statement…’if done right’…is either misinformed or full of themselves.  If there was a good and reliable way to do them that assured predictable long-term results, then so many people wouldn’t be talking about the different methods of how to do it. If one way really worked everyone would be doing it and that would be the end of the discussion. There are some basic principles of fat harvest, concentration and injection that are currently used, but no one doctor can claim any proprietary method of how best to do fat injections. Much of the science of it remains unknown at present. In addition, anyone that talks about long-term fat injection results is either speculating or commenting on their own personal observations as there have never been any long-term clinical studies that have shown in a quantitative objective manner how stable the results are.

That being said, I think fat injections is a very useful technique and the only good solution for some aesthetic augmentation issues. But the patient has to know that the result is unpredictable and can not be assured or guaranteed how well it will work. Fat injections are great as they are a natural tissue but the result is a gamble.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am Yoga Weight Loss System interested in skull reshaping. I am a 28 years old man and the point being that the width of the upper part of my head above the ears is big and rounded on both sides. Can it be reduced and flattened ?

A: The wide or more square head shape that you have is due to a pronounced temporal ridge which is where the top part of the skull joins/transitions to the skull bone at the side of the head. This actually a ridge or line that starts in the forehead and goes to the back of the head. While this is always  a transition area like two walls coming together in a corner but is usually a gradual transition. Your temporal line is very acute almost being 90 degrees.

 This area can be snoothed down and made to look less square or wide. But the important question is whether it is worth the scalp scar trade-off to do so for the skull reshaping benefit. To access the area an incision is needed across the top of the head so both sides can be treated. While the skull width can be reduced, I am not sure in your case that is a good tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my cheekbone broken two years during an assault. At the time, I did not have it fixed by having plates inserted and it has since healed. My cheekbone is flatter on this side and my face is slightly asymmetrical and uneven. Since then, my friends misinterpret my facial expressions thinking I am smirking or grimacing when I am not. I am sensitive about my facial asymmetry and am wondering if it is worth the time and effort to repair. Thank you so much.

A: Cheekbone or zygomatic fractures display a classic pattern of displacement when fractured. The body of the cheekbone rotates down and inward with partial displacement into the maxillary sinus. This reduces the prominence of the cheek bone by this inferior rotation, making the cheek flatter and the face asymmetric. Primary surgical repair repositions the cheekbone back into place and holds it there with plates and screws. But once the fracture is healed, this is no longer a good option in most patients. Rather than moving the bone, it is usually better to treat the facial asymmetry with an implant to restore fullness to the cheekbone. This is a far simpler surgery than major zygomatic osteotomies and repositioning. A one-sided cheek implant is a simple surgery that takes 30 minutes of surgery and improves much of the aesthetic asymmetry of the fractured but healed cheekbone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a mini tummy tuck with muscle repair 6 years ago. I am unhappy that my belly button is lower than I would like. I have some loose skin elasticity—is it possible to pull my belly button back up to more of the placement it was prior to my surgery?

A: One of the potential disadvantages of a mini-tummy tuck is that the belly button can be pulled down because, unlike a full tummy tuck it is never transposed. It remains with the skin that is pulled down and often looks and is lower. Usually this is not a problem in most cases but umbilical distortion can occur as the funnel of the belly button is turned downward. This problem can be difficult to fix but not impossible. There are two potential approaches. First, a superior umbilical lift may be possible based on the elasticity of the surrounding abdominal skin. By removing a small crescent of skin at the upper umbilical hood, there can be some upward tilt to it giving a slight superior repositioned look. Secondly,  there is a vertical umbilical lift which is very similar to the lollipop breast lift. This is the most effective approach to lifting the belly button but will result in a vertical scar that is left in the wake of where the belly button used to be. The choice of either umbilical lift approach depends on how much upward movement one wants to achieve. I would need to see a picture of the current position of your belly button and then another one which shows where you would like it to be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting my chin narrower as it is too wide from the front view. In addition, it is longer on one side than the other. I know that you can burr or shave down the chin to reshape it. I have some concerns and questions about the procedure.

1.  I want my chin to be narrower by at most 1/4 inch.  I want the same squared shape only narrower from the frontal point of view.  Is that easier to do by cutting out a long narrow vertical strip in the middle of the chin and pushing the sides together thus preserving squareness or is it just better to burr down tubercles of chin on outer edges?  I do NOT want a pointy chin nor an oval chin.  Slight square is better just like it is, but narrower. Don’t know how narrowing would change smile lines as they arise from chin though.  Nor am I clear of how the jawbone to chin transition would change in a burring.  May be difficult to preserve some squareness.  Don’t want too small a chin for my size. I also fear that a subsequent face lift will feature a prominent bony masculine chin.  

2.  I do NOT want my chin profile to be changed.  I think it is fine as is.  Would burring down of sides affect this?

3.  Also want the bottom of the chin to be evened out.  One side is longer than the other.  Hopefully the asymmetry in the rest of my face (the right side is fuller in the cheeks) won’t be accentuated by any chin narrowing.   

4.  Will intra-oral approach allow you to visualize the submental nerve adequately?  Will it increase chance of infection?

5.  Percent likelihood of numbness of chin?  Tongue?  Typical resolution time? Ever seen permanent numbness?

6.  What is most catastrophic thing that could go wrong with a chin reduction? Lower face paralysis or worsening of my already incompetent lower lip?

A: In answer to our questions:

1) It is better to simply burr down the side of the chin for such a small amount of chin narrowing. Technically I actually use a reciprocating saw to remove the bone. That stills keeps it square in the front view, just narrower by the amount removed. I don’t think this would have any great impact on the smile lines nor change the jawline-chin transition…it is just being made slightly smaller/narrower in the frontal view. Also, a facelift does not really pull and shift tissues in the chin area so I don’t think that it will accentuate or create more of a square chin appearance.

2) Taking down the sides of the chin will not affect its horizontal projection. (profile) The most projecting part of the chin bone is not being affected.

3) The longer vertical side of the chin can be reduced as well. The computer imaging done previously should show you what the impact the chin surgery has on the look of the rest of your face.

4) The intraoral approach will allow the mental nerves to be seen completely. Intraoral surgery does nto increase the risk of infection unless an implant is being placed. There is nothing wrong with going from beow the chin through a skin incision, it is just that it is not necessary. (no advantages in doing so)

5) There will always be some temporary numbness of the chin because the mental nerves have been exposed. I have not seen permanent numbness from an isolated chin reduction/burring procedure. No risk of tongue numbness, the tongue is innervated from the lingual on the floor of the mouth which is a long way away.

6) There are no catastrophic events that can happen from this procedure. It is just an issue of aesthetics, how close do we come to the desired aesthetic goal. Lower facial paralysis is an impossibility because the facial nerve the moves the face is back near the ear. If your lower lip is incompetent to some degree I will resposition the mentalis muscle and chin soft tissues to try and improve that problem at the same time.

Dr. Barry Eppley

Indianapolis, Indiana