Facial Rejuvenation

Q: Dr. Eppley, I am interested in making my face look better, some sort of facial rejuvenation surgery if you will. While I am only 50 years old, I feel like I look much older. Here are some starting pictures of me for your assessment.

While I’d like to fix the “bag” effect under eyes, the depressions in my cheeks, and the acne scaring…I’m looking at all possibilities as well. My nose has a slight hump in it (might be called a dorsal hump from looking online) and my nose seems a little wide at the top (I have no idea what the proportions of a nose should be relative to my face).

You can see the skin wrinkling in front of my ears, I’m guessing some sort of facelilt procedure to fix that as well. Another doctor told me that the bags under my eyes might go away with a full or advanced facefilt as well.

I don’t care for my smile and would love to have a bigger smile that shows more of my teeth.

A: Thank you for sending your pictures. You really don’t have herniated fat under your eyes, what you have are alar festoons. These are bags of tissue that appear over the highest part of the cheekbones. They are not easy to eradicate but are treated through a lower blepharoplasty procedure not any form of a facelift.

The skin wrinkling in front of your ears would be treated by a limited form of a lower facelift.

The mouth area would be treated by a corner of the mouth lift that turns up the corners as well as makes the corner to to corner mouth distance bigger.

Your nose could be improved any a hump reduction and shortening and lifting of the nasal tip.

All four of these facial rejuvenation procedures could be done at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, . I have a multitude of facial asymmetry issues stemming from a mild Kaban/Pruzansky birth defect. I have a confirmed hemifacial microsomia that has primarily affected the eye, orbit, and cheek regions and ramus of my jaw. They really bother me and I want to fix some of them. I am not sure whether to go for orthognathic surgery and a custom cheek implant. Or to do all implants on the affected side. If you place an implant in the cheek (malar-ygomatic arch), will this also make the affected eye and brow look more bizarre as it will look even further back with the projection of the cheek? How do I improve my facial asymmetry without looking even more bizarre in other words. I also have a skinny face with the cheekbones projected like you see in fashion models (though I am no model!). Will custom implants look bizarre as I do not have a tremendous amount of overlying fat? I have dealt with this for almost 30 years as I am almost 29 and I want to move on with my life.

A: Thank you for your inquiry about facial asymmetry correctiobn. There is little I can tell you by your description alone. To be most helpful and to properly treatment plan, I would need pictures of your face and bite and a 3D CT scan.

With this information meaningful recommendations can be made. In short, if your bite is fine and your occlusal plane is reasonably level, custom implant augmentation of the smaller side would be appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Scar Revision

Q: Dr. Eppley, I am interested in cheek scar revision.  I have got scar tissue in my mouth and cheeks from multiple cheek procedures. cheek (implants, cheek implant shave down, cheek implant removal, revision implant placement). I also had jaw and chin work done two times. It caused lots of scar tissue. My lips move weirdly now and is thick in my cheeks. Can scar revision be done to cut out the scar tissue? Can anything can be done to reduce it or remove it? Thank you for your time.

A: I would not think about scar tissue removal as that would just make things worse. You fundamentally have a tissue deficiency (which is really what scar tissue really is) which is why your lip vestibule is tight and tethers your lips from a normal outward movement and stretch. What you really need for a cheek scar revision is scar tissue release and the placement of small interpositional dermal-fat graft to help restore lip flexibility and prevent recurrence. The placement of an autologous tissue graft between the lips and the underlying maxillary bone fills in the tissue gap that is created by the scar release and returns needed healthy tissue to the area.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, I am looking to do multiple surgeries to correct issues with my face structure. I have a receded chin and a round, weak jawline. I’ve seen a few pictures of a custom jaw angle wrap around, and think this might be ideal to fix these issues. How much would this procedure improve my chin projection, would I be able to have the chin in front of lips? Looking at my photos, is it possible to get an angular jawline?

My nose has a low radix, and looks very off to me. I don’t really know if anything can be done, what are your thoughts?

I’m not sure about this, but it seems I have a recessed mid-face and very recessed under eye area. Would a custom midface implant be ideal for me? Would I get enough projection to have a positive orbital vector? Would this implant do anything significant to orbital rims?

A: Thank you for your inquiry and sending your pictures. I would agree that a custom wrap around jawline implant would make a big difference for you. Custom infraorbital-malar implants could be designed to give you a positive orbital vector and higher infraorbital rims. A custom paranasal-maxillary implants would add projection to the midface. The nose could be improved by dorsal augmentation to build up the bridge and low nasal radix.

I will have my assistant pass along the cost of the procedures you on Monday

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, I am interested in correction of  numerous facial deficiences which all are located on the left side of my face. Attached are 3 pictures of my face that show the areas of concern. I took one straight-on picture and another two pictures each showing one side of my face.

When looking at the straight-on photo, you can see that my jaw is skewed to one side with the right side being fuller than the left. You can also see that my chin is tilted to one side as well. What is slightly harder to see in the photo is that there are some soft tissue discrepancies between my cheeks and if you can see, there is a slight “indent” on my right side that isn’t there on the left. I thought that this could be because of the prominence of the mandible underneath and the prominence of the cheekbone above that creates this indent but I would love to hear your opinion on it as well. The deficient cheekbone that I mention is on the left and it may be difficult to see without being in person or taking a picture at a very specific angle. However, you can easily see that the zygomatic arch on the right is more prominent and that holds true to the entire cheekbone as well. I cannot wait to hear your opinions on these pictures. Again, thank you for your time.

A: Thank you for sensing your pictures. I can not disagree with any of your observations about your face. What you really have is a near total left-sided facial asymmetry which affects many structures from the ear to cheek and down along the jawline. The facial asymmetry is greatest at the jawline and lessens as it ascends superiorly towards the eye. Undoubtably, as is often the case, they are heavily bone-based with some soft tissue component to them.

On a practical basis one starts by addressing the skeletal issues and the use of 3D CT scanning and the design of custom jawline and cheek implants is really the only way to effectively treat it.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Augmentation

Q: Dr. Eppley,  I am interested in jawline augmentation. I had a chin implant placed several months ago. I have attached my before and after pictures. As you can see, the chin augmentation is an inadequate improvement –  I have basically gone from having a recessed chin to having a weak one. I want my chin to line-up with my lower lip. I suspect I would need a genioplasty + implant to attain this.However, I do like the height the implant has given to my chin, it has given me a stomion ratio of 2.00 and this is a feature I would like to retain. I also like the enhanced lateral chin width and the squarer shape. Square chins look better than round chins on men in my opinion. My gonial angle I would like reduced to 115-120° range, I’m unsure whether this is a realistic goal though. What is the maximum possible jaw angle augmentation with implants? I’ve read that it is 12mm. 

A: Thank you for sending your pictures of your chin augmentation results.. For a large anatomic chin that is not much of an improvement. Based on your pictures and goals, I can make the following jawline augmentation comments:

1) It is rarely a good idea to combine a chin implant on top of a sliding genioplasty in an effort to substantially increase its width. That works best when the goal is merely to ensure that the chin is more square or to cover the back ends of the osteotomy cuts.

2) A sliding genioplasty may provide the greatest horizontal projection but in doing so will make the chin less square and potentially even more narrow.

3) Based on #1 and #2, the best choice is a custom wrap around jawline implant alone. Your existing chin implant has help to serve as a chin tissue expander which allows for greater horizontal projection than otherwise could have been achieved initially.

4) Vertically lengthening the jaw angles (decreasing the mandibular plane angle) in theory can be done any amount, particularly when it is a custom implant design, and can even be surgically placed. But the greater the implant drops down the jaw angle the risk of the muscle not following the implant edge increases. (masseteric muscle disinsertion) Such an aesthetic complication is very difficult and in many cases impossible to correct secondarily…so it is a problem best avoided. It is impossible to predict before surgery what patient may experience this potential problem. I have dropped jaw angles down 25mm and not seen it…then I have seen it occur in drops as ‘minimal’ as 10mms. As a general rule it is best to not get ‘greedy’ and keep a reasonable amount of vertical jaw angle lengthening in the 8mm to 12mm range.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Rejuvenation Surgery

Q: Dr. Eppley, I am interested in forehead rejuvenation surgery. First, I have deep horizontal wrinkles across my forehead and vertical wrinkles in the corrugator area. These wrinkles have been effectively controlled with Botox for many years. The only thing is that if Botox is not done properly, I get pointed eyebrows and a Spock type look.  This is the reason why I’m interested in a brow lift and corrugator resection – to eliminate the wrinkles, precisely place the eyebrows, while providing a more permanent solution to the wrinkles.

On top of the wrinkles caused by my powerful brow muscles, I have numerous shallow boxcar acne scars in the upside down triangle area of my corrugator area (with the apex of the triangle meeting with the bridge of my nose directly between my eyes).

Several years ago I had fat grafting to the entire forehead and for a while (due to both the fat graft and swelling from the procedure) all of my forehead issues, including the boxcar scars, were greatly smoothed out. But the swelling went down and my powerful forehead muscles eventually eliminated the fat that was grafted. This is why when I saw that you do forehead implants, I got interested.

My hope would be that a properly placed forehead implant would have the same effect that the fat grafting/swelling initially did from the fat grafting procedure, which was to raise and stretch to skin thereby smoothing the scars.

A: Thank you for the forehead rejuvenation surgery clarifications and let me provide some commentary about them.

1) A brow lift is not a cure for horizontal forehead wrinkles. Its effect is that of a brow lift not a wrinkle reducing operation. There is no surgical equivalent to what Botox does in terms of muscle deanimation. While it may have some temporary benefit in terms of lessening the depth of the wrinkles, it is most certainly not a permanent solution for them. (for which there is none) One undergoes a browlift for the goals of lifting the brows as that is the one assured benefit of the surgery.

2) Corrugator muscle resection through an upper blepharoplasty is best approach to do it, not through a superior browlift. Again it will help with the glabellar furrowing but it will not completely eliminate the furrows and it is not a permanent cure or solution to them.

3) A forehead implant will help stretch out the skin and provide some smoothing effect. But this is completely dependent on its size and thickness and there is a delicate balance between forehead implant that provides the best smoothing effect and one that makes the forehead look too big.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Horn Reduction

Q: Dr. Eppley, I came across this website and saw some before and after images of craniofacial surgery. (forehead horn reduction) I was hoping to get some more information on this surgery. I’m very uncomfortable going out wearing my hair off my face as my forehead appears to have two bumps on and if I do I’m often asked if i’ve hit my head, which I get quite embarrassed by. It would be great to get some advice and what actions I can take. I look forward to hearing from you.

A: Thank you for sending your forehead pictures. You have the classic ‘forehead horns’ that are benign paired bin bumps that appear on the upper forehead. They are development in origin and are actually not that rare. They can be successfully removed using of two approaches. The first approach is to simply burr down the prominences so they are more confluent with the rest of the forehead. (forehead horn reduction) The other approach is to build up the forehead area around the horns to make for a smoother albeit fuller or more convex forehead. The choice depends on the patient’s aesthetic preferences for their overall forehead shape

Dr. Barry Eppley
Indianapolis, Indiana

Skull Reshaping Surgery

Q: Dr. Eppley, I am interested in skull reshaping. I have a very flat head from the back which makes my head look too small for my face and I need a big amount of augmentation to get the skull shape I’m looking for. After reading your blogs it seems that I need a 2 stage procedure using the tissue expander to get the maximal amount of scalp stretch needed for a good augmentation. I have few questions I want to ask you related to the 2 stage procedure

1.Are you the only one who preform skull reshaping 2 stage using Tissue Expander or it can be done by any skilled plastic surgeon?

2. Can an implant up to 3 cm be done if it was desired by a patient with a very flat back of head ?

3. Does this procedure performed by doctors in europe ?

4. My little brother has the same issue and his planning to get the procedure too when he will be able to pay for it. But he is very concerned if it’s gonna be available to him 10 years or 15 years from now?

A: Thank you for your skull reshaping surgery inquiry. In answer to your questions:

I can only speak for the procedures that I do on a regular basis. I can not speak to what surgeons elsewhere in the world may perform a two-stage skull augmentation procedure.
2) It is usually wise to stay in the 2 to 2.5 cm augmentation thickness range.

3) I would not know if any doctors in Europe perform these type of skull augmentation procedures.

4) I see no reason why such skull reshaping procedures would not be available in the immediate or far future.

Dr. Barry Eppley
Indianapolis, Indiana

Nasal Dorsal Augmentation

Q: Dr. Eppley, I need a lot of nasal dorsal augmentation. I looked at your gallery and like your work very much. And I would like to know if you would recommend rib cartilage or donated cartilage or artificial material in patients with very low nose bridge. Looking forward to hearing from you. Thanks!

A: There are three material methods of nasal dorsal augmentation, each with their own advantages and disadvantages. A synthetic implant, like ePTFE, offers an off-the-shelf augmentation material that can be carved and customized for each patient and offers an augmentation method that is assured of a smooth contour and not to warp after placement. But it does come with some risk of infection being a synthetic material. Autologous rib grafts offer the most natural material and lowest risk of infection. But it does requires a donor site, costs more to do and has some risk of warping and asymmetry. Cadaveric rib cartilage is like an intermediary material between an implant and one’s own rib cartilage. It is not an implant but then again is also not like one’s own rib cartilage either.

As you can see there is no perfect dorsal augmentation material and rhinoplasty surgeons often use what they are most familiar with or have used in the past. Having used all three nasal augmentation materials, my preferred choice comes down to educating the patient and having them decide which nasal material is most appearing to them. The only caveat in your case in that you said you need a lot of augmentation. I would have to see what a lot means as that may sway the decision in favor of one of the nasal augmentation materials.

Dr. Barry Eppley

Indianapolis, Indiana