Your Questions

Q: Dr. Eppley, I am 5’ 9” tall and fairly skinny. I have no extra fat but some loose skin from my three pregnancies. While I am not crazy about the loose skin, what bothers me the most are the many stretch marks that I have. They are around my belly button and lower as well as out onto my hips. The stretch marks on my hips are the worst, being wider, redder and more noticeable than those on my stomach. Therefore I would like to get rid of them the most.most noticeable, so I would love to get rid of those at least. I was hoping to get rid of most stretch marks and extra skin with a tummy tuck but I don’t want to go through with it if it does not provide a major improvement in my unsightly stretch marks.

A:  The main benefits of tummy tuck surgery is the removal of extra skin and fat and the tightening effect of the stomach that it provides. Any improvement in associated stretch marks from pregnancy is a secondary benefit that is largely coincidental. The stretch marks that will be removed is what lies within the outline of the tummy tuck excisional pattern. Your surgeon can mark that out for you so you can see exactly what stretch marks will be removed. Stretch marks around the excisional pattern, particularly above the belly button, will shift position to a lower location below the new belly button for many of them. Stretch marks on the hip, which is largely outside the zone of the tummy tuck cutout will not be removed/improved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a transgendered MTF and had botched silicone injections in my face in the cheeks years ago.  Over the years it has enlarged especially my right side.  Will 5-FU/kenalog shots work to bring down this very noticeable mass in my cheeks?  How much are each shot? 

A: I am assuming that this cheek mass is reactive scar tissue to the injected silicone. Unlike conventional scar tissue, this would represent a comglomerate of fibrous tissue (scar) and silicone oil rather than just scar tissue alone. While kenalog or combined kenalog/5-FU injections may help soften the scar tissue which contains the silicone droplets, it will obviously not get rid of the molecularly-stable silicone. The key question is then will scar injections reduce and soften the cheek mass that you have? That is an unknown question that no one can predict. Despite the unpredictability of the outcome, I see no downside to doing so. It is a simple and relatively inexpensive treatment ($225/injection session) to do, Positive results could be expected to be seen in three to six weeks after treatment. Whether more than on session would be needed would be based on the response to the first set of injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my upper and lower jaw advancement done 7 months ago and was not too happy with the results. I recently had chin and jaw implants together with a rhinoplasty done. I have also had some facial fillers placed under the lower eyelids and on the upper cheeks. Regardless, I still feel like my mid-face is flat and would like to know what can be done (if any) to make it more convex.

A: While I do not have the advantage of seeing any pictures of your face, I will assume by your description that you have either a malar or a combined orbito-malar skeletal deficiency from an aesthetic standpoint. This may or may not include a maxillary-paranasal deficiency as well although your recent maxillary advancement surgery may have improved that concern. Knowing which of these areas needs augmented is obviously important. But for the sake of completeness let me review all three areas.

Cheek implants are probably very familiar to you but there are four basic styles to consider that augment different areas of the cheek. To improve facial convexity, the cheek implant must provide anterolateral projection, with more anterior than lateral. This can be placed through the mouth like most traditional cheek implants. If a concomitant infraorbital deficiency exists, an orbito-malar implant can be used which is placed through a lower eyelid (blepharoplasty) incision. When a deficiency around the nasal base exists, paranasal or a premaxillary implant can be used. The difference is that one pushes out the base of the nose on the sides (paranasal) while the other pushes on the base of the columella (premaxillary) to open up the nasolabial angle.

Without seeing pictures, I could not tell you which type of midfacial implant(s) would be appropriate for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I feel my brow is too prominent/large. I had one surgeon tell me only a full “sinus setback/type III” will be the only way to fix it. However, can the bones be modified/burred enough to make a difference? I want the side/profile to be more flat and less prominent. I feel my forehead profile is the only element that makes people look at me strangely sometimes and it makes me very uncomfortable. I read that the supraorbital rims can easily be reduced even with just brow remodeling. Is this true? I appreciate any feedback you can give me, even if it is that I am likely to only benefit from the aggressive sinus setback type of surgery. I just need to know if there is an adequate amount of change that can be achieved with some mild bone shaping and with soft tissue modification to effect a real improvement (not perfection, but more feminine appearance, in profile as well) or if I’ll have to do the full reconstruction. I know an x-ray is the only way to know for certain.

A: In looking at your photos, the brow bulge does appear to be from the frontal sinus. But whether that needs to be burred or setback by osteotomies will require a lateral skull film to best answer that question. In some cases in women, I have done a little burring of the brow  bone prominence and building up of the forehead above it to create a smoother more convex forehead. That can be a very good alternative to setback osteotomies for mild amounts of brow bone bulging like yours.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My nose has been broken a couple of times, and I have a deviated septum. I am curious what it would take to straighten everything out–and what it would look like.

A: Based on this one picture, I have done some imaging based on what I think is achieveable in an open septorhinoplasty procedure. Straightening a crooked nose is one of the most difficult challenges in all of rhinoplasty because it is never just one element of the anatomy that is off. It is never simple and requires a complete dismantling of the support structures and rearrangement. This means an open septorhinoplasty with septal straightening and graft harvest, inferior turbinate reductions, nasal osteotomies, spreader grafts to the middle vault, a columellar strut and nasal tip narrowing. As you can see your nose would be much straighter and as assessed by the flow of the dorsal lines from the forehead down to the tip of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking about getting a custom jaw/chin implant. I think I have a small chin, vertically small jaw as well as narrow. Since I live in another city I can’t find any experienced surgeon. (or simply one I can’t trust) Would it be possible to get a CT scan done (of mandible and maxilla) and send it to you so you can build a wrap around jaw implant. How much would it cost excluding CT scan and the actual surgery? And then maybe I can find a surgeon in my city who can perform the actual surgery. I don’t want to get a genioplasty. Your help would be much appreciated.

A: Your assessment of your lower face is correct. Your entire jaw is vertically short from the chin back to the angles. Short of mandibular and/or chin osteotomies, a custom jawline implant that vertically extends the lower and chin is needed. That does require a 3-D CT scan which can be gotten in your city. It is then sent to a manufacturer to make a model of either just your lower jaw or your entire craniofacial skeleton. It is off of that model from which I can make a custom wraparound jawline implant. That design in your case is bigger in the chin area and tapers back because the length of your jaw angle is minimally deficient compared to your chin. I can certainly and the total cost to do it is $7500. (cost of model, fabrication and production and sterilization of implant) While you are certainly free to look around to find a surgeon who will place it, my guess is that won’t be easy because they have never seen an implant like that before and may be very uncomfortable (not to mention inexperienced) in its placement. It is not as simple as placing a standard chin implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year-old male that underwent a pectus excavatum correction for a severe deformity. Although initially thrilled with the results, I have experienced a disappointing recurrence as is evidenced by the photos. I would do about anything at this point to have a normal looking chest. I am active and healthy, I box and lift weights. I take medication for high blood pressure, which is controlled, and I take synthroid for hypothyroidism. I do not smoke or drink, and aside from the scripts I am drug free. I would appreciate any and all information you may have on an injectable sternal procedure to help build it up.

A: Injectable sternoplasty is a concept that comes from injecting a moldeable bone cement into small lower sternal pectus excavatum defects. A pocket for the material was initially made through a small incision to receive the material which was molded into shape after it as placed, After having done a handful of cases, the bone cement material (which was intended for use for other skeletal issues) was withdrawn from the commercial market due to economic issues of the manufacturer. (not any material problems) That not leaves us with having to consider to use other materials that can be placed either through injection or a small incision. Fat injections remain as the best current method because it is truly injectable and is a natural material. And most everybody has some fat to donate. The biggest and well known problem with fat injections is that its survival is variable and can not be precisely predicted. This is why it is always overdone/overfilled. Other more material-assured results are injectable hydroxyapatite granules or beads. Which although very simple, safe and uses a well known biocompatible material, I have yet to do that just yet.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had breast implants placed 12 years ago. One of my implants is encapsulated. That breast nipple is leaking an oily green substance. Can this be a leak?

A: Since your breast implants were originally placed in 2000, you have saline breast implants if they were placed solely for cosmetic reasons. The only silicone breast implants that were placed at that time were those for breast reconstructions. When saline breast implants leak, they deflate and exude water which is not an oily substance. In addition, every breast implant has a surrounding layer of scar (capsule) which for some implants become abnormally thick and have varying degrees of hardness. (capsular contracture) This capsule serves as a very firm barrier that even silicone gel can not escape unless a capsular tear occurs. That is a long description to say that what is coming out of nipple most likely has nothing to do with your underlying breast implant per se. I suspect that the hard capsular contracture may be pushing against the breast duct/glands causing these secretions.

Dr. Barry Eppley Indianapolis, Indiana

Q: Dr. Eppley, I have narrow forehead and temporal area and I have wide jaw line. I want to get a wider upper face to equalize my wide lower face. Can temporal implants help me? Because of my deep set eyes, I am concerned that any such widening may make them look even deeper.

A: Based on the picture you sent, I can see the aesthetic value of temporal implants in terms of improving your desire for upper facial widening. Based on the size of the temporal implant, your temporal region can have varying degrees of increased convexity. I do not see how any widening in the temporal area will have any effect on the appearance of your eyes as they do not affect the prominent of the lateral orbital rim, one of the circumferential bones around the eye. As long as you do not increase the brow prominence, you will not deepen the eye area.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I wrote you about orbital rim implants some time ago. I am 42 years old and am interested in rim implants or canthopey or both. Do you see any problem in having only canthopexy to reduce scleral show and slightly tilt the eyes? The thing is when I tried fillers (which didnt change my problem much at all to be honest) the surgeon said that permanenet implants feel rigid that you can feel them all the time? I really would like to simply narrow and sharpen my eye shape, just concerned that a lot of people get either a “stretched look” or nothing at all?

A: When it comes to lifting up the lower eyelid to reduce scleral/orbital show, lateral tendon procedures are not going to shorten the ‘clothesline’ and lift the lower lid margin. That is simply asking too much of the procedure. There is a good correlation between the lower eyelid margin and the underlying bone support. The lower the bony orbital rim, the more likely the lid margin may also be lower or at least have less support. Therein lies the value of orbital rim implants, raising the bony rim and helping to push up the eyelid. and its lid margin. Lateral canthopexy has as role in the placement of orbital rim implants by providing suture support to the closure of the lower eyelid incision to decrease the potential of postoperatve ectropion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 38 years old and had 3 children by age 22 that I breastfed. I have small breasts which is cool with me, I just want them a little perkier. My tummy and love handles need to go. I can work on my legs in the gym and they have always been strong. Can my breasts, tummy and love handles all be done at the same time?

A: When you put breast and tummy reshaping together as a single procedure, that has become known as a Mommy Makeover. Most forms of breast reshaping include implants with some type of lift although breast lifting can be done alone. If volume is not an issue then breast lifts by themselves will be just fine. Tummy tucks, mini- or full versions, almost always include liposuction of the flanks. (aka love handles) Most people envision a near circumferential waistline reshaping and tummy tuck scars stop at the hips. So fat reduction beyond that needs to involve liposuction to extend the 180 degree effect of a tummy tuck into more of a 270 degree wrap around waistline effect. It would be very common and would have a more profound body change if what was affected by pregancies is reversed in a single operation. This explains the popularity and the effectiveness of the Mommy Makeover of which you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about the best material to use in an ethnic rhinoplasty. (I happen to be Asian) Surgeons seem to prefer rib cartilage because they feel it is safer. How big would the scar to take it be? Could you provide me with more information about using rib cartilage. I have looked at some before and afters with a couple of different docs and it seems you are able to do more with rib cartilage to achieve the rather large difference I am looking for as far as height of the bridge and tip goes. What do you think of the noses in the desired result photos I have attached?

A: In further detail about rhinoplasty augmentation, there is no question in my mind that the better long-term material for many ethnic rhinoplasties thqt require significant dorsal augmentation as well as tip projection by grafting is cartilage. To not limit oneself by the amount of graft material, rib cartilage is always better because there is no restriction on volume. While rib graft rhinoplasty is harder on both the patient and the surgeon, and there is a resultant scar, your own tissue is always best over the rest your long remaining lifetime. Speaking of the scar, it is about 3.5 cms long low along the costal margin on the left or right side. (lower end of the middle of the rib cage) I usually take it from the opposite of the patient’s hand dominance so there may be less discomfort afterwards with less arm/body motion. While some surgeon’s use the rib graft as a whole block that is carved for dorsal augmentation, I find it much better to cut the rib grafts into tiny 1mm pieces (cubes) and rhen placed those inside a wrapped collagen sheet, making a moldeable implant. (aka diced cartilage graft) Then once it is placed it can be shaped into the desired form and amount of augmentation. Once held together for a week with the nasal splint, it becomes quite firm amazingly quickly. This not only makes for a customized shaped graft but avoids the biggest problem with dorsal rib grafts…malposition and warping. There is also the possibility of a little external molding when the splint is removed for adjustment until it becomes one firm solid graft.

In looking at some of the noses you sent, the question is whether your nose can achieve that look. I think the best way to think about it is probably not. There noses are more refined and, most importantly, they have thinner skin…the final determinant that ultimately influences much of a rhinoplasty result. But with significant dorsal augmentation, a columellar strut to increase nasal projection and a tip graft, you will end up a lot closer than where you are now.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a receding chin and wonder if you can help me get a reolution for this problem. I guess a sliding genioplasty will benefit me and it will also correct the vertical growth of the chin which a chin implant will not. And will this surgery make my already narrow chin look more pointed if the chin is brought forward by more than 5 mm.

A: Here is a computer prediction of a sliding genioplasty for you. That is the correct procedure given the magnitude of your chin deficiency problem. I would also add submental ljposuction to give a better neck profile as well. You are correct in assuming that a 10mm to 12mm advancement will likely make your chin look slightly narrow in the frontal view. That can be overcome by adding a small pre-jowl implant in front of the osteotomy which will make the sides wider and lessen the palpable notching on the edges of the osteotomy where it joins the body of the mandible posteriorly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am hoping you can help me with my situation: Long story short, I had my upper lip overfilled with silicone injections years ago and I just underwent a lip reduction two months ago. Now I am left with multiple hard and misshapen lumps on my lip and I am very embarrassed about it, plus they hurt and pull as well. I am looking into some kind of injectable scar lump treatment and you seem to be the Dr. who can do it per my internet searches on the topic. The Dr. who performed my reduction thinks they will go away in time, but these are literal knots in my lips and it is by no means normal. I am worried they will never heal or “settle down”, and don’t want to take a passive route.

A: The interesting question, of course, is what are these lumps in the lip. Having done a lot of lip reductions, such lumps or irregularities are not common or expected. I would have to assume that they represent residual areas of silicone material/scar. I doubt of your lip reduction procedure removed all of the silicone material as the reduction largely removes mucosal tissue while most of the silicone is likely in the orbicularis muscle.

Injectable scar injections are not unreasonable and can have few adverse effects if not overdone. I prefer to use either low dose Kenalog or Kenalog mixed with 5-FU to treat early postoperative scar formation. Whether your lip lumps (residual areas of silicone?) will respond to such injections is uncertain but I can certainly appreciate your concern and desire to be proactive about them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering more about the chin implant and appreciate the computer imaging that you have done. My question is do I really need to enlarge my chin so much? Actually as far as I know the largest chin implant by Medpor enlarges chin by 7mm. Actually it looks better from the side view, but I am also was worried about asymmetry of the face from the front view. So I thought  to put the Geniomandibular Groove implant to right side only to correct it. But while would it correct the asymmetry, I would not look better from the side view. By using the Medpor RZ chin implant, is it possible to trim in operation or I would need to order jaw model by CT for custom implant because of the asymmetry?( http://eppleyplasticsurgery.com//blog/tag/custom-chin-implant/  ) How long would it take to get and much would it cost? Do you think I need a custom chin implant?

A: The imaging shown is just a point to begin the discussion of the changes you would like. Certainly the amount of horizontal chin projection can be less. But I would not go less than 7mms because anything less than that would not make much of a noticeable change.

Geniomandibular groove implants will not provide much horizontal projection, maybe 1 to 2mms. They are used primarily for vertical lengthening of 3 to 5mms and to fill out a notch at the lower mandibular border.

Your best off-the-shelf chin implant option would be the Medpor RZ extended square implant of 7mm projection. The wings of the implant could be intraoperatively modified  to try and compensate for your facial asymmetry along the jawline. I would expect improvement in the asymmetry but not ideal correction as this is a stock implant not a custom one…and your problem is obviously unique to your anatomy and not a ‘stock’ problem.

While custom implants are ideal for any patient, it is always a question of whether the cost is necessary for the amount of aesthetic improvement. That will always depend on the patient’s problem and how asymmetrical or unique the bone problem is. At $3500 extra costs to get it made, one does have to give that good thought. I think it depends on what one is prepared to live with when it comes to the result. In your case, if you can live with improvement but not ideal symmetry than I would go with  an off-the-shelf implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a small area on my left breast of gynenemastia from use of steroids years ago. The lump is approximately 3/4 inch round 1/2 inch thick. Its not very noticeable but I would like to have it taken out. How is ti done and how easy is it to do?

A: With such a small gynecomastia on just one side, by description an areolar gynecomastia type, that could be simply removed as a short outpatient procedure done under either local anesthesia or IV sedation. Its removal would be done through a small inferior areolar incision. No drains would be used and no sutures would need to be removed. (all dissolveable sutures under the skin) You could shower the very next day without any problems getting the surgical site wet. You could also return to work the next day provided that it is not a highly physical job with a lot of arm motion. One could resume working out in a week or so  with chest exercises deferred until two to three weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Mentor saline breast implants placed in 1994 and now one has deflated. I need to find out what my options are to replace them.

A:Having a current saline implant deflation, regardless of when they were placed, leaves you with several options. First, you could simply replace the deflated implant only. With an established pocket (provided the deflation has not gone on for months), a saline implant can easily and painlessly be replaced even under local or IV sedation. While that is the simplest thing to do, most women would understandably be concerned about the other implant deflating soon thereafter. (particularly in your case where they are now 18 years old…beyond what most saline implants would be expected to remain intact) Therefore, the second option would be to replace both implants with new saline implants. Once you have suffered a deflation, however, most women do not want to endure another one and would like implants that at least have a chance to last the rest of your lifetime. With that consideration, the third option would be to replace both old saline implants with new silicone gel (gummy bear) breast implants which will not suffer the problem of deflation. They will have the best chance of lasting the rest of your lifetime. Of course, there is always a fourth option of simply removing both implants and not replacing them at all. For understandable reasons this is rarely done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you feel it is possible to create an aesthetic male face even with my Class 1 hypertelorism? I understand that it can be found to be an attractive feature in women (such as Jackie Kennedy), but I can’t really seem to find any examples of good looking male face with hypertelorism. Do you know of any? Thanks!

A: First degree hypertelorism, as you have been mentioned, can be attractive in females. You have mentioned Jackie Kennedy as an historic example but Uma Thurman would be a more recent illustration. When it comes to men, however, I have never heard it so described and can not think of any example where it is.

The spacing between the eyes can be improved by several facial camouflage strategies. I have not seen a side view of you so I can not say how successful they would be in your case. Building up the bridge of the nose, usually with an implant,  is a classic example of decreasing the distance between the eyes. This is best done in patients that have a low or wide nasal bridge. The higher the nasal bridge, the less the eyes look far apart. In addition, widening the lower face can also help camouflage it. Cheek and jaw angle implants in particular help widen a the lower 2/3 s of the face.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a question regarding injectable scar treatments. What is the difference between 5-FU and Kenalog? What do each of them do to help a scar/scar tissue?

A: There are two types of scar injections that are currently available. The use of steroids, specifically triamcinolone (kenalog), is an historic and classic injectable approach. Triamcinolone is a synthetic corticosteroid that has a significant anti-inflammatory effect. It works on scars by either inhibiting or breaking down the cross-linking of collagen fibers, which is the backbone of scar formation. Dosing and frequency of Kenalog injections is critically important as it can have side effects such as soft tissue atrophy and tissue thinning. For this reason, lower doses are usually used, such as K10 rather than the more concentrated K40, and injections sessions should not be spaced more than 3 or 4 weeks apart.

5-FU is a well-known drug used as a chemotherapy agent against cancer for several decades. It works by inhibiting DNA replication which is important in stopping cancer cells which usually multiply faster than normal cells. In dermatology, 5-FU is most commonly used topically (as a cream) for treating actinic (solar) keratoses and some types of basal cell cancers of the skin. (e.g., Efudex or Carac) It is thought that it works in scar problems because it blocks collagen synthesis which might help to control excessive scar formation. It does not have the side effects of corticosteriods but injections are still done only every month or so, mainly to see how it is working.

I often combine the two, Kenalog and 5-FU, as an injectble combination when either it is a known problematic scar or a scar that has failed to respond to Kenalog injections. It is unknown whether one is superior to the other as a primary scar therapy.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have an acquaintance who recommends your work and I very much look forward to seeing your ‘predict my face’ response and getting work done in the near future. I am looking to significantly increase the masculinity of my face by doing dramatic work on my jaw, chin, and lower third of my face. I am looking for the classic, masculine hollywood jawline. I also seem to be carrying some buccal fat that’s obscuring my jawline and cheekbone structure. I was wondering if you feel that if I lost some significant body fat if I would look noticeably better.

A: I have done some imaging based on chin and jawline/angle changes I believe you are looking for which is a more pronounced jawline from one side to the other. You do have a horizontally short chin with some vertical deficicieny as well. Because of your ethnicity, you do have larger masseter muscles and adequate vertical jaw angle length. In the imaging I have done the changes that I think will result from a square chin implant (8 to 10mms in projection) and 7mm lateral jaw angle implants. In an ideal world the chin and jaw angle implants would be connected as a solid implant but that would require custom implants made off of a 3-D model. In lieu of that effort, a three-piece off-the-shelf implant approach could be used. The fundamental difference between the two approaches is that there would not be a smooth and built-out jawline between the chin and the jaw angles.

Lastly, I would agree that a buccal lipectomy would be a nice complement to the jawline changes as it provides a concave facial contour between the cheek and the jawline…a classic male model look if you will.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am an HIV positive 56 year old male. My CD4 count is near 500 and my viral load has been undetectable for over 15 years. I have severe facial lipoatrophy as a result of the adverse effects of antiretroviral therapies. I wish to explore the possibility of cheek implants.

A: By your pictures,  I can see that you have a type 5 Facial Lipoatrophy with severe submalar tissue atrophy. I have found submalar cheek implants to be very helpful in all types of cheek lipoatrophy although in type 5 they alone may not be sufficient. While the implant will help build out the cheek prominence, and particularly the submalar area, the lowest portion of the buccal atrophy (where the tissues are pinched in under the cheek bone) may be not be changed adequately. In these type cases I have added a dermal-fat graft under the implant in the lower buccal space to get a more complete correction. Dermal-fat grafts can be harvested from any scar area on the body if you happen to have one. In addition, You might also consider temporal implants to improve the deep temporal hollowing from the lipoatrophy as well. In many type 3 to 5 facial lipoartophy, augmentation of the tenmporal and submalar cheek area can together help make for a better improvement of the gaunt facial look.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have narrow forehead and temporal area and I have wide jaw line. I want to get a wider upper face to equalize my wide lower face. Can temporal implants help me?

A: Thank you for your inquiry. You may well be correct that temporal widening alone using temporal implants or combined with forehead widening may be beneficial for better facial balance. I would need to see some pictures of your face to make a more definitive determination. I will also be interested in seeing the frontal picture of you to see how wide the cheeks are also. It is really a question of whether the location of the temporal expansion can create enough of an effect to make a visible difference in upper facial width.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am looking for a correction for my hypertelorism (wide set eyes). I have measured my intercanthal distance at 36 mm, which I believe puts me in the “mild/moderate” range. While I will pursue it if it is the only option possible, I would love to avoid large-scale craniofacial surgery if I could. I have heard of surgeons moving eyes up or down a few mm using implants and wall burring. Would the same be possible for my eyes, simply horizontally? I would love any of your advice on the matter in terms of solutions to my problem!

A: Thank you for your inquiry. In answer to your questions, let me first address moving the eyes or changing the perception of the orbits by some alteration inside the orbital bones. While some vertical movement of the eyeball can be done (more upward than downward), there is no horizontal movement that can be done. The location of medial rectus muscle and the ethmoid and lacrimal bones prevents any inward movement of the eye by changing the intraorbital space volume. There is also the limits of the medial canthal tendon and the inner eye aperture. That can not be moved inward unless the bones are moved.

Your diagnosis of hypertelorism is correct and by appearance and intercanthal measurements you would be classified as a Type 1 hypertelorism. Such mild cases of hypertelorism are almost never surgically corrected due to the magnitude of the operation. Hypertelorism surgery requires a large scalp incision, a frontal craniotomy and removal of interorbital bone to move the orbital boxes inward. While I would have no doubt that this operation can be successful in you, the risks of infection, forehead bony irregularities, temporal hollowing, permanent scalp scar and frontal facial nerve injury all make this operation reserved for those patients that have more severe Type 2 and 3 hypertelorism problems.

In short, there are no simple solutions to your hypertelorism and the aesthetics of your case do not justify the major surgery needed to improve it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m unhappy with my asymmetric face and would like to have a nose job and chin implant to correct it. Would it be possible to correct it with standard Medpor chin implants? Which chin implant it would suit to me better to correct it and can I get a view how would I look after these changes to my face.

A: Thank you for your inquiry and sending your pictures. I have done some imaging on your nose and chin. Your rhinoplasty is straightforward, meaning that tip shortening with narrowing and a little lift and dorsal line straightening with narrowing of the upper nose with osteotomies would be done. Your chin is severely short and I could argue that an implant is not the best choice given the limits of how much horizontal advancement can be obtained with off-the-shelf implants. (only up to 10mms) But I have imaged what I think the most that a chin implant can achieve. When it comes to chin implant type, there are advantages and disadvantages to either silicone or Medpor materials. While some surgeons and patients get focused on their theoretical biological differences, I have never found them to be distinctly different in that way. I am more interested in what styles and sizes of chin implants the various manufacturers offer. In your case, I would likely choose a two-piece square chin Medpor implant of 11mms horizontal projection.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want a fuller butt to compliment the rest of my body. I don’t have any pictures at this time but I’m a black female with what they call a flat butt that doesn’t go with the rest of my body. What are my options for getting a bigger butt?

A: Buttock augmentation can be done by two techniques; implants and fat injections. Each as their own advantages and disadvantages. By far the most common buttock enlargement method today is fat injections also known as the Brazilian Butt Lift. Fat injections offer the advantages of simultaneous body contouring from the liposuction fat harvest and a natural method of enlargement that has a fairly quick recovery. It’s one disadvantage is that there is no predicting how much of the fat will survive. As a general rule, fat injections can produce only a modest enlargement in buttock size. Synthetic implants have the advantage of a permanent method of buttock enlargement that can produce a larger result that is maintained. Its disadvantage is that it requires a small intergluteal scar and has a longer and more difficult recovery.

While many patients can choose between implant or fat injections, some will have no choice but to have implants. If one has little or inadequate donor fat to harvest, then fat injections can not be performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about the lateral commissuroplasty procedure. Could a corner lip lift be done in a manner which would not shorten the upper lip or “plumpen” the lips (these things are mentioned as coming along with a corner lip lift but I would rather not have them as I think they would be top feminine). I also realized you do brow shaping. My eyebrows arch out on the ends and I would rather them lay straight across (or at least close to that). Could this be done? Finally, could all these procedures be done in one session?

A: You appear to have some misconceptions about the corner of the mouth lift. It does not affect lip size or shorten lip length. Whether a corner of the  mouth procedure is done to lift up the corner or to widen horizontal lip length, there is no change in the rest of the lip shape or size.

From a brow bone shape standpoint, it sounds by your description that you have too much lateral brow bone protrusion. That can easily be reduced through an upper eyelid incision by burring down the side of the brow area that does not have the frontal sinus lying underneath it.

Both the corner of the mouth and brow bone procedures could be done at the same time. Combined it would be a two hour procedure done on an outpatient basis.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in implants to correct my jaw asymmetry. My jaw angles are very asymmetric and I feel I would be more attractive if my facial asymmetry was corrected. I have always been curious about art with respect to beauty.  What is beauty?  I’ve concluded that beauty is not only in the eye of the beholder but also in the symmetry of the viewed.  When you see a symmetric butterfly, it looks beautiful.  When you see the symmetry of a supermodel, it is beauty.  So this is something that I have become aware of over the years… and others have as well.  In fact, there is now an iPhone app that can rate your attractiveness by measuring your symmetry…  and guess what actor ranks the highest…  It’s Brad Pitt.  His left side of his face is exactly like his right side.

I have read your comment about not being able to reach a perfect match on anyone’s facial asymmetry, but instead improving on it.  I like that realistic goal.  I personally would be highly satisfied if I used a string that was measured and cut to reach from the corner of my left outer eye to the corner of my left corner back jaw (mandibular ramus) and have that string reach the same distance on the right side of my face as well.  It currently does not match.  But if it did, I would be a happy man.  And I also understand that even if I had this result, the symmetry would not be perfect since the position of the corner jaws may be different in the 3-D x-y-z coordinate system.

A: While I have found that perfect symmetry can be difficult to achieve in facial surgery, that does not mean it is not the goal. There are different methods in trying to achieve that symmetry regardless of the location of the implants. Traditional, and still the most commonly done, method of facial implant surgery is to pick out the implants based on a more or less artistic assessment of the patient’s needs. There is no precise method of matching the implants to the underlying bone shape or knowing exactly what the outward changes will be. As unscientific as that is, it works most of the time when the patient’s facial bones are symmetric and the patient isn’t overly detailed or looking for perfection. When it comes to improving facial asymmetry, however, it is easy to see how an unexact science applied to a variable problem is prone to some degree of a persistent level of asymmetry.

To counter these issues, an ideal approach is to make custom implants off of a 3-D model. When this is economically feasible, it is easy to see why this is better than ‘eyeballing’ it.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The right side of my skull is caved in and bulging therefore causing an asymmetrical appearance on my facial profile. From my right temple area, the skull leans towards the right, almost appearing to sag to the right side of my head. I wish to straighten that side so that both sides of my skull are structured straight up and are symmetrical. The pictures limit how much you can actually see, I believe an x-ray would do justice to my explanation. The problem is it bulges outwards. Whether it is muscle atrophy or bone, the cause was due to the way I would lay down on my side at 12 years old. The palm of my right hand would be pressed into my skull pushing the temple muscles upwards or inwards causing the deformed bulge. I basically used to use my right hand as a pillow, so my whole right face was subjected to being pressed into causing the disfigurement. It wasn’t the best way for me to lay but it was the most comfortable at the time. I put a lot of strain on my neck area, as my head and palm pressed into each other. Months afterwards, I noticed pain in my neck. Whenever I moved my right arm in a punching motion, I would feel a shock of pain surge through my neck causing me to yell out in pain. Migraines followed for sometime then stopped. My jaw was affected as well since my palm would push into it while my head rested on it. I can see a noticeable difference when I look at the right side of my maxilla and the left, the right is pushed in, so the top right row of teeth slant inwards. In response, it changed the alignment of my whole top row teeth in that it slants to the right. This is something I can see when I open my mouth, and using my tongue can feel the change including when I bite down on things. Then there’s the problem with my right nostril. It feels like it’s always stocked up in that whenever I sleep it tightens up so that I barely breath out of that side of my nostril. Also, whenever I’m in a warm environment, it closes and I’m forced to breath out of one nostril. I believe I damaged that area as well by applying pressure and somehow pressing inwards into the right side of my maxilla/nostril. It’s not congestion. So, here I hope is a general outlay of my problem and the problems along side it. I honestly believe an x-ray is much needed because a visual will better explain what words fail to. I can feel it and I’ve lived with the changes and a thorough scan of my head and neck will show you what I’m talking about.

A: You are correct in that the pictures don’t do justice to the skull/facial problems as you have described it. It would be highly unusual to reshape bone by any form of external pressure beyond the first few years of life but it is possible. That issue aside, I would agree that the best way to determine of your skull and facial issues are from bone or soft tissue deformity is to get an x-ray study. I can make those orders to any facility in your geographic location. The question is what type of x-rays would be best. The best type of x-ray to get is a 3-D CT scan of your craniofacial skeleton. That would provide an absolutely clear view of your skull and facial shape. In an ideal world, we would even get a model made from these x-rays which could even be used in treatment planning/designing the surgery. But from a cost standpoint, the bare minimum x-ray study you should get is a plain skull and facial series.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  You have a great website and blog! I especially enjoyed reading about the mandibular angle implant procedures that you’ve done and your sensitivity to avoid asymmetrical results. My biggest concern is to correct my asymmetrical jaw.  The left vertical side extends to cause the horizontal jaw line to extend about a 1/2 an inch lower than the right.  This may not seem like much but it is enough to slightly make the left side of my nose droop down in an asymmetrical way.  What I wish I could have done is the right side of jaw lowered to match left perfectly and to do this with mandibular angle implants that would be about a 1/2 inch longer (vertical) on the right than the left. This would give me a symmetrical yet stronger jaw.

A: To lengthen the vertical height of the mandibular ramus, a vertical lengthening jaw angle implant needs to be used. This is one of the two types of off-the-shelf preformed jaw angle implants that are commercially available. It is the more difficult of the two types of jaw angle implants to place because a portion of it must go below the existing lower bone border of the jaw.
When it comes to correcting jaw angle asymmetry, I would avoid the use of the term ‘perfect match’ as I can tell you that is unlikely to occur. A realistic goal is improvement in the symmetry of the jaw angles. Perfect symmetry may happen but less asymmetry is a more likely outcome. Jaw angle implants are the most difficult of all facial implants to place.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I came across your site, and was looking through the breast augmentation surgery, the results look really great. I’m a transsexual, I do have some breasts after being on hormones for about 4 years, and I was wondering would it to be too hard to do breast implants to someone who doesn’t have a whole lot of breasts?

A: If you look at a lot of breast augmentation results, it will become apparent when seeing before photos that many patients have little to no breast tissue. In fact, many of the best breast augmentation results come from those that have little breast tissue and nice taut skin. In such patients the resultant breast mound from implant placement attains a nice round shape.  As long as the implant size chosen is not too big, the breast shape will not look unnatural.

In short, it is not difficult to place breast implants when there is little breast tissue present. This is what is commonly seen in many patients. The partial elevation of the pectoralis muscle with the overlying skin provides adequate space for almost any breast implant size. The limits of breast implant size is the base diameter of the chest/breast. As a general rule, it is good practice to match that diameter with the base diameter of the implant in each patient.  

Dr. Barry Eppley

Indianapolis, Indiana