Should I Have Hairline Lowering By Surgery Or Hair Transplants?

Q: Dr. Eppley, I am a 26 year old female, I am very self conscious about my forehead and have been for years. I am so tired of feeling embarrassed and having to hide it and limiting what I can and cannot do for fear of it showing. I’ve been researching transplants to lower my hairline. I’ve ran into your website and was wondering if you do hair transplants to lower hair lines? If so a round about cost to have it done? I’m really hoping you can help me and I can get this done and feel 110% more confident with myself.

A: Lowering the hairline, as you may know, can be done by either scalp flap advancement or hair transplants. There are advantages and disadvantages with either approach and neither one is perfect. So let me review these with you. The advantages of hair transplants for lowering the hairline is that it does not create a fine line scar along the frontal hairline (although it will create a scar in the back of the head from the harvest site) and does not involve a true surgical procedure under general anesthesia. Its disadvantages is that it will take at least two hair transplant sessions and close to eight hours of procedure time to get the new hairline properly filled in and up to six to nine months to se the final result. A scalp advancement for hairline lowering creates an immediate hairline lowering in a fairly simple procedure under anesthesia. (like a reverse browlift) It disadvantages is the fine line scar along the frontal hairline and the possibility that some hair transplants may be needed along the scar line for better camouflage. (may or may not be needed)

When comparing these two, it is also important to look at the costs differences between the two. Two hair transplant sessions will definitely cost more than a surgical hairline lowering procedure.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Facial Reshaping Surgery Do I Need After Orthognathic Surgery?

Q: Dr. Eppley, I am interested in facial reshaping surgery. I am a female with a recessive lower chin and a minimal jawline. I have had orthognathic surgery twice now, which has improved my teeth but not the balance of my face. I still have a very convex facial profile with an extremely long vertical jaw angle. Here are some images of my face. I hope these will help you to assess my situation. My last surgery was 11 months ago in which my upper and lower jaw were brought forward to correct an overbite and an open bite. I do feel that my upper jaw (between nose and upper lip) is more elongated than before. As you will see from the photos it is difficult for me to close my lips. I realize that this cannot probably be fixed, however I would like my face to look less long and narrow and my jaw line  more defined. My jaw is rather vertical in angle. Any advice very much appreciated.

A: The forward positioning of the maxillomandibular complex has placed a strain on your lip closure as this was not the bony relationship that your lips were ‘designed’ to function over. Along with the upper lip lengthening, these are not rare changes that occur with such maxillomandbular forward movements. In addition, loss of the jaw angle can occur with sagittal split ramus osteotomies (SSRO) of the mandible particularly when the lower jaw moves forward. This can be accentuated in females who may already have a thin and slightly high vertical has angle position initially.

The way to make your face look less vertically long and not so narrow is through a combined sliding genioplasty and jaw angle implants. Small vertically lengthening jaw angle implants (7mm vertical length and 3 to 5mms width) will create more defined jaw angles but not over power the upper face. A sliding genioplasty of the movements of 3mms forward and 6mms vertical reduction would shorten the chin length and also help push up the soft tissue chin pad. This may provide some potential benefit also to reducing the lip strain through a better lower lip position at rest.

Dr. Barry Eppley

Indianapolis, Indiana

Is An Extended Tummy Tuck What I Need?

Q: Dr. Eppley, I am researching tummy tuck surgery and trying to see what can be done for me. I have attached pictures to help you see my severe abdominal overhang problem. I would like your professional opinion on which course of action would be best. 

Extended Tummy Tuck Result Dr Barry Eppley IndianapolisA: It is important to realize that there are different kinds of tummy tuck surgeries depending on the nature of the abdominal problem. While traditionally divided into a mini and full tummy tuck, that historic classification by today’s methods is too simplistic. I divide tummy tuck surgery into six different types and levels which vary based on the amount of tissue removed, the location and extend of the incisions and whether liposuction plays an additive role in improving the result.

There is no question you would get tremendous benefit by an extended tummy tuck. (level 5) This is a tummy tuck where the removal of excess tissue wraps around the side of the waistline or encompasses about 300 degrees around the waistline. (it does not cross the midline in the back like a full circumferential body lift does) If you do not chase the excess skin around the waistline (a traditional or level 3/4 tummy tuck stops at the hip bones) you will be left with big dog ears of skin  and protruding tissue over the hips. In addition, it is important in any tummy tuck particularly when there is an overhanging abdominal pannus (apron) that a simultaneous pubic lift be done. This is often overlooked because it is hidden underneath the pannus but will become unmasked when the pannus is removed. Thus the excisional pattern of the tummy tuck should incorporate the design of a simultaneous pubic lift in its pattern. I have attached some picture showing a before and after an extended tummy tuck with a pubic lift. Note that the resultant tummy tuck scars wraps almost completely around the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Will Gynecomastia Reduction Surgery Get Rid Of My Man Boobs Completely?

Q: Dr. Eppley,  I am interested in gynecomastia reduction surgery. I’m a 36 year old who has had man boobs my whole life. I’ve tried dieting and exercising to try and get rid of them with no success. They’ve caused great embarrassment for me over the years. I won’t swim in public and am very unconfident when it comes to dating and any sort of relations with the opposite sex. 

Gynecomastia Reduction Surgery Indianapolis Dr Barry Eppley IndianapolisA: Your feelings of embarrassment and some degree of social restriction is not rare and exactly replicate what many men with similar problems state about their gynecomastia problem. Once gynecomastia has formed, there is no diet or exercise regimen that is going to get rid of it. While in extreme weight loss cases, breast tissue can be lost in a male, many men with gynecomastia do not need extreme amounts of weight loss. Gynecomastia reduction surgery can be very effective and is usually most effective when open excision is combined with liposuction. This is an outpatient procedure done under general anesthesia that takes about two hours to perform.

The success of gynecomastia reduction surgery is based on how completely the removal of breast tissue is done. There is always the risk of removing too much breast tissue causing a crater deformity or not taking enough leaving a residual areolar protrusion after all the swelling has gone down. This is the delicate balance plastic surgeons walk when performing this type of male chest surgery. For these reasons, there is about a 15% to 20% risk of desiring a revisional or touch-up surgery to optimize the chest contour.

Dr. Barry Eppley

Indianapolis, Indiana

Is Sliding Genioplasty The Best Way To Make My Face Less Round?

Q: Dr. Eppley, I want to hear your expert opinion on whether a chin implant or a sliding genioplasty or some other thing is more appropriate for my jaw. I have attached pictures from 3 angles of my lower jaw, at a default, relaxed face. Notice my big jowls and rounded face. I have been told (by a few oral/maxillofacial surgeons) that a sliding genioplasty would probably be better than a chin implant because, as one surgeon put it,….an implant usually doesn’t create the angles I would need for the roundness to soften up a bit and for significant loose skin to pull. I don’t mind a slightly round face, I just don’t want to look like a balloon on the lower half of my face.

In your experience, how true is this???

A: A properly designed chin implant can create more angles than than a sliding genioplasty. A sliding genioplasty brings the chin forward but will make it more narrow in doing so. That is fine if that is the frontal change that you want….which usually works well for a female. Most males want a more square chin as it comes forward with a genioplasty which will not create that effect unless the bone is split and widened. But in doing so there will be a dip behind the chin in the jawline. Many bone-based facial surgeons often know how to do one chin approach (sliding genioplasty) but often do not have much experience with the array of chin implants, preformed and custom, that are currently available. Both implants and a sliding genioplasty are effective chin augmentation operations but their effects can be dimensionally different. It becomes imperative to know what each of them can aesthetically do and then apply it to the aesthetic needs of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

What Do I Need To Improve My Recessive Lower Jaw With Extra Skin?

Q: Dr. Eppley, I have this grinding type noise when I open my jaw on my right side. I have had orthodontic treatment years ago and have a underdeveloped lower jaw. I consulted my orthodontist about the grinding noise possibly being linked to my underdeveloped lower mandible. He told me that my jaws are lined up correctly and I should do nothing about this grinding noise. At the beginning if my orthodontic treatment a lower mandibular advancement was recommended, however I decided at that time that I would just have orthodontic treatment without surgery. After orthodontic treatment I have a clearly recessive jaw with extra skin around my lower jaw area. As a craniofacial and maxillofacial surgeon I would highly consider your opinion in what my next step should be.

A: Many people have asymptomatic grinding noises which emanate from their temporomandibular joints. This is usually caused by the disc in the joint which may catch on opening as the mandibular condyle comes forward.  Underdeveloped lower jaws with Class II malocclusions (orthodontically corrected or not) have a greater propensity for these disc noises. But as long as one is having no pain in the TMJs or any difficulty with opening, there is no treatment indicated. For the recessive jaw and loose skin around it, this can be aesthetically addressed by either a sliding genioplasty or a chin implant. Either approach has certain advantages and disadvantages that must be assessed based on each person’s anatomy and aesthetic desires. The first place to make this determination would require an assessment of pictures from the side and front views.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Flat Back Of The Head Surgery Do I Need?

Q: Dr. Eppley, Please help me I have flat head from the back and it looks ridiculous and people are laughing at me . And I’ve been suffering for over 22 years. I want to ask do you you have plastic surgery for the back of my head and please tell me the solution. I have attached a picture for you to see how bad it is.

A: Thank you for sending your picture. I will admit, and I have seen many flat back of the heads, that you do have an impressive one. It is one of the flattest back of the heads that I have ever seen. There is no question there is improvement to be had with flat back of head surgery, it is just a question of how much and what effort do you want to put into it. There are two basic approaches, either a single stage or a two stage approach. In a single stage approach, a custom implant or PMMA bone cement is use to create a moderate improvement. In a two-stage approach, a first-stage tissue expander is placed to stretch out the soft tissues. Then a custom implant or bone cement is placed to get a more significant change. (at least double that of the one-stage) Either way, you definitely can get a positive improvement from the very flat back of the head that you have with these occipital augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Will Secondary Skull Reshaping Cause Complications?

Q: Dr. Eppley, I am interested in skull reshaping surgery. I think I have scaphocephaly but I’m not sure. My head shape looks like those of the kids in the picture when I was younger and had received surgery thank God. My head shape has gotten better significantly but it is still narrow and my forehead seems to be protruding outward. I thankfully have a full head of hair but am afraid of what will happen when I go bald. I just want to talk you more in depth and possibly send some pictures. As you can see from the pictures my head shape isn’t as bad but it is more of a cosmetic issue. My only concern is of complications that could ruin my appearance for the rest of my life or going bald from complications from the surgery. Hopefully you can get back to me asap I’m excited for your reply as I have found someone out there that can help!

A: Your picture does show the remnants of having originally had scaphocephaly or sagittal craniosynostosis. As you have mentioned the front to back distance of your skull is just a bit long with a slightly protruding forehead and a somewhat narrow skull width. I assume hidden within your hair is a scalp scar from the original infantile craniosynostosis surgery. The question now is whether any effort at improving your skull shape justifies the effort. I do think the forehead bulge can be reduced, certain skull areas smoothed out and some width added using your existing coronal scalp scar. This is not a skull reshaping procedure in my experience that is associated with any major complications, only minor aesthetic ones.

Dr. Barry Eppley

Indianapolis,Indiana

How Soon Can I Have A Revision Rhinoplasty?

Q: Dr. Eppley, I have a few questions after my rib graft rhinoplasty surgery. I’ve noticed that the very top of my nose bridge has started to warp to the right. It’s at the very top and it’s kind of hard to notice in person, it’s more apparent to me and then in pictures. Also a bump/hump has developed on the upper nasal bridge. I just didn’t know what possible things could be done about this if this indeed is a problem. Also, I know I’m jumping to conclusions, but if there had to be a revision surgery, how long would I have to wait? I’ve done research on revisional rhinoplasties and some doctors suggest waiting 6 to 12 months. But I saw that this was more for patients who thought their nose tip was too bulbous or the nose was too big, so the doctors suggested to wait for the swelling to go down. Another doctor suggested that he’s performed surgery as soon as two months on patients who’s revisions would be easier to fix sooner rather than later. How long would I have to wait to do a revisional rhinoplasty?

A: The timing of revisional surgery for any procedure fundamentally comes down to knowing that one has a stable target. This translates into three issues to consider: all swelling has resolved, the tissues have shrunken down and adapted to the new underlying framework and one has had enough time to accommodate to the new look. When all of these factors are considered, the timing of revisional surgery will vary based on the exact rhinoplasty procedure that was done. In general, most plastic surgeons would say that six to 12 months is when any type of revisional rhinoplasty can be done. This is, of course, a general statement and each nose and the concerns must be considered separately.

The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. Patience can be difficult but critical with secondary surgery. You don’t want to play ‘wack a mole’ with revisional surgery by jumping in too soon.

It is true that nasal dorsal issues are different then nasal tip issues because of the quicker resolution of swelling and tissue adaptation. Since your specific concern appears to be at the upper end of the rib graft in the radix, this type of revision might be considered sooner than other post rhinoplasty concerns. Some slight deviation and/or step-off of the upper end of the rib graft is not uncommon and can often be felt. How visibly significant that is will determine whether any revision is worth the effort.

The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. This is particularly true when one has had multiple procedures as one would like only undergo one revisional procedure. You don’t want to play ‘wack a mole’ with revisional surgery but jumping in too soon.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Facial Asymmetry Be Fixed?

Q: Dr. Eppley, I’m not sure what is wrong with my face. My eyes seem misaligned and not symmetric. The thing is when I look in the mirror I can’t see much wrong with my face it’s only on photos. I’m not sure if the pictures make it 10x worse or if the mirror makes it look like nothing is wrong. I don’t really know the aspect in which people see me. I have a great deal of anxiety due to this and i’m not sure what’s wrong or how it needs to be corrected. What can you recommend ?

A: I think there is no question you have a significant orbital dystopia of the right eye. In the perfectly oriented facial photo, you can see that the right eye is lower than the left as well as the eyebrow on that side is also lower. This is somewhat masked in your other pictures because you tilt your head to the right side, probably as a subconscious reaction to mask the facial asymmetry as it makes it appear more symmetric than it really is. The difference in the horizontal pupillary levels is about 5mms lower on the right than the left. Also you can see that your nose is deviated to the right, one side of the chin is slightly longer on the affected side and the eyelid on that side has some laxity with a more ‘droopy’ position. If you had a 3D CT scan of your face you would see how different the right orbital ‘box’ is compared to the left.

All of the most significant signs of orbital facial asymmetry could be improved by a collect of procedures done around the eye. These would include orbital floor augmentation, right lateral canthoplasty and a right eyebrow lift would be helpful for improved facial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana