Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a custom skull implant. I’m a 52 year-old Asian male and am very interested in your skull augmentation procedure. In my case it would be the higher region of the occipital lobe, about 45 degrees between horizontal and vertical (I’m extremely flat and no volume). Could you please send me as much information as you can regarding the nature of the procedure, costs, risks, scars, recovery, and the maximum possible increase in convexity that can be achieved to that occipital region. Thanks so much.
A: Thank you for your inquiry. Crown of the head augmentation is best done by a custom skull implant made from a 3D CT scan. The critical question is whether the existing scalp laxity will allow for maximum convexity to be achieved as a one-stage procedure or whether it may require a first stage scalp expansion. That would depend on how how much thickness the implant must have to achieve what one sees as maximum convexity. As a general rule, up to 12mms or so can be comfortably done as a one-stage skull implant. Increases of 15mms or greater almost always require a scalp tissue expander first.
I would need to see pictures of your head in profile and do computer imaging to help determine the important consideration of implant thickness required. While custom skull implants can be made to any dimension and thickness, the limitations in their design are in how much the scalp can be stretched to accommodate the underlying added volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in deltoid implants. I was involved in a car accident many years ago which resulted in nerve damage to my left shoulder and caused complete atrophy to my deltoid muscles. I’ve been told that muscle replacement isn’t an option. I was told about the possibility of implants to surround the shoulder to at least give a more natural appearance. I would like more info as to if this is a possibility for me and an estimated cost.
A: Loss of deltoid muscle mass after nerve damage is very common. Since muscle transplants are not an option for the shoulder area, shoulder augmentation can only be done by either fat injections or deltoid implants. Fat injections are always an option for soft tissue augmentation although how much fat will survive and persist is always their potential downside. Deltoids implants made from a very soft solid silicone material offers assured volume retention but comes with uncommon but potential risk of infection.
The one issue with deltoid implants in cases of shoulder atrophy is how well the existing size of available implants may match the defect. Fortunately silicone body implants are very shapeable during surgery so they usually can be adapted to just about any size soft tissue defect.
The cost of a single one-sided deltoid implant would be in the range of $4,000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have developed a small forehead osteoma and I want it removed. I am 38 years old but still wear my hair back, and show all of my face, wear light makeup, and do not want this on my forehead. I could get away with bangs but I really want to keep my face open and clear. I have no idea why I have developed this, I did hit my head as a child in this area, and may have hit it over the years, but it has just shown up in the last year front and center sad to say. I am looking for a ballpark price to have it removed, not an exact I understand, but a ball park quote.
A: I would need to see a picture of your forehead osteoma to determine its location and the best way to do its removal. The other issue to be addressed, particularly if it is sitting over the frontal sinus, is whether it involves the frontal sinus or just sitting on the outer table of the frontal sinus. Its location and frontal sinus involvement can make a very big difference in how it is treated. If you do not have a CT scan of it, then that needs to be done so the proper diagnosis can be done. Until alt his information is obtained the costs of surgery can not be precisely determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like further information on scrotal reduction surgery. I am 57 years old and my testicles are loosening with age. I have never had high and tight testicles but would like to. I have no idea how much testicle size influences the sack or is the sack responsible for keep them up. I saw the scrotoplasty photograph on your site and would be interested in looking like the photo.
A: Like breast mounds in females, the overlying scrotal skin envelope (sac) of the testicles is responsible for their shape and degree of sag. The more scrotal skin that exists, the lower and more loose the scrotum will hang. In the long-term the size of the testicles probably does have some influence on the amount of scrotal skin that develops. But testicular size can not be changed and their influence is a very long-term effect.
A scrotal reduction or scrotal lift (scrotoplasty) involves the removal of a central strip of scrotal skin done through the natural raphe that exists between the two scrotal halfs. Many scrotums actually have a midline raphe that creates a bit of a vertical cleft through the bottom of the scrotum, making a perfect place to place a fine line scar. This is an operation that is performed as an outpatient under anesthesia. Dissolveable sutures are used with an overlying glue as a topical dressing. One may resume showering the very next day and normal underwear may be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant revision. I had 375cc filled to 425cc saline over the muscle implants placed 20 years ago. I got them after the birth of my first child. I went on to have 4 more children and breastfed all of them. I am 5’4″ and 130 pounds. I feel best at 110 pounds but the rippling of the saline implants is terrible and embarrassing at that weight. I would really like to lose weight, deal with the rippling and switch to silicone implants. Was hoping to increase size to 525-625 if possible. I am worried about animation deformity with under the muscle. I do not like that possibility at all. Can it be avoided? The doctor’s here are very conservative size wise and the ones I have consulted with do not like or offer silicone. They did say switching from over to under would be an very easy procedure but I would like to avoid saline implants. One Dr from several states away recommended fully under muscle implants. Didn’t even know that was possible. Another recommend acellular matrix grafts with silicone under muscle to minimize but not eliminate any visible movement. Have heard great things about your work and would really appreciate you opinion and ideas on what can be done.
A: Thank you for your inquiry. Let me help clarify all of the breast implant revision options you have presented as they cover every single onethat is available. First of all, the shape of your breast mounds and position of your nipple-areolar complexes are extraordinarily good for someone who had had four children and breastfed them after the original breast augmentation procedure. It is very rare to find someone with your history that does not need a major breast lift at this point. So the approach of simply changing breast implants is a viable one for you.
There is no question that you want to switch to silicone implants. I am shocked to hear that in your area they don’t use silicone breast implants. In contemporary breast implant surgery saline implants today make up less than 25% of implants used and are only used because of their lower costs. They are are inferior implant in regards to feel and longevity compared to silicone implants. While silicone implants will not completely eliminate all rippling, they will go a long way to eliminating the majority of these palpable and visible implant folds.
The next issue is that of either keeping your existing implant location or switching to an under the muscle location. You have essentially decided that already in that any under muscle location will cause an animation deformity. That is an unavoidable issue since most submuscular positions are really partially under the muscle and the side of the implant is only right under the skin. Thus when the pectoralis muscle moves the implant is ‘unchecked’ at the side and it moves in that direction. Maneuvers such as placing ADM grafts to totally cover the implant edge or moving muscle from the side of the chest wall up over the implant can be done to reduce/eliminate that problem. However, increasing the implant size to 600cc makes making a complete submuscular pocket impossible. (implants are too big to get full muscular coverage) The use of ADM grafts is an option for coverage but that will add over $6500 to the cost of surgery for implant cost and time of placement, exponentially increasing the cost of breast implant revision surgery.
I see no problem with switching your existing implant size to 600cc plus, but as you can see you can not have everything that you want. (no animation deformity, no visible rippling, reasonable costs) Thus what I see as the most acceptable option for you to go with a high profile, round smooth silicone implant that remains in your current subglandular position. I prefer the submuscular position almost always and the animation deformity may not be that significant but that may not be risk that is appealing to you
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have frontal bossing on the upper forehead below the hairline on either side. Many specialists say this can be easily treated with fat grafting but what about the long term side affects? I would greatly appreciate any details.
A: The treatment of frontal bossing can take two very different directions. One is a reductive approach to frontal bossing which involves burring down the prominent forehead bony protrusions through a hairline or more posterior scalp incision. The opposite approach is an augmentative one where the areas around the frontal bossing is built up. This is usually best done by adding bone cement material to the ‘deficient’ areas around the frontal bossing also done through an incision similar to the reductive approach.
Whether one should have an an augmentative or reductive approach to their frontal bossing is one of aesthetics. Which type of change of forehead change will look the best? That would depend on the each individual patient and their degree of frontal bossing and forehead shape. I would need to see some pictures of your forehead to better answer that very important treatment decision.
The use of fat grafting in the treatment of frontal bossing falls into the augmentative approach. It differs from bone cements in multiple ways including the elimination of an incision (good thing) but with unpredictable fat survival and rarely creates a very smooth forehead contour. (bad things) But if augmentation is the best aesthetic treatment, these risks may be worth it including the potential need for a second fat grafting session. However if a reductive approach is the best aesthetic choice, fat grafting would be a poor treatment choice no matter how well it was performed or how much fat survives. One wants to avoid making the overall forehead too big.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about septal perforation repair. I haven’t touched cocaine in years, but unfortunately, my perforation has grown. It’s between the size of a pencil eraser and a dime. I’m crushed and afraid and want it repaired. So far, it’s still standing (my nose) and I want to keep it that way. I read most traditional surgeries do not succeed but stem cell is working for larger holes. Can you help?
A: While it is true that the larger a septal perforation is, the lower is its success rate. But that does not mean that a septal perforation repair can not be successful, it is just that they are not easy and are often performed poorly. When talking about ‘stem cell therapy’, which is not really clinically available and is a misrepresentation of what is available ( injection options include autologous fat injection which coincidentally may contain some stem cells or platelet-rich plasma (PRP) which is a platelet conecntrate), such injections are not a method by themselves that can heal a septal perforation. Any such injections can be used as a concomitant treatment with conventional surgical techniques. PRP injections are what is used in septal perforation repair. It is important to realize that whether PRP injections are used before or during septal perforation repair, there is no medical evidence that proves septal perforation repairs are more effective because it is used. But because it is a natural extract from the patient, there is no harm in using it. In short, the use of PRP injections in septal perforation repair is largely based on the hope that the platelet concentrate may help in some fashion with the healing problem of a known difficult internal nasal problem.
The best approach for septal perforation repair is from above through an open rhinoplasty. This allows mucosal flaps to be raised on both sides and a PDS plate combined with temporalis fascia and a cartilage graft to be properly placed and covered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal reduction surgery. I was wondering if a complete reduction of my temporal muscle (including the non skin bearing part) was possible? And if so would it only require a surgical procedure? Or also a botox injection on top of that? Thank you very much for your time.
A: When you speak of complete temporal reduction of the muscle I am deducing from your description that you mean both the anterior and posterior temporal areas. The anterior temporal region is the skin bearing portion of the temporal muscle to the side of the eye that extends a few centimeters back into the temporal hairline. This temporal area can not be reduced surgically due to its thickness and location. It is treated by Botox injections to shrink down its size. The posterior temporal region extends behind the anterior area the whole way to the back of the head. The larger by surface area but thinner posterior temporal muscle area can be surgical reduced very effectively. Thus, surgical temporal reduction refers to the posterior area above the ears while injectable temporal reduction refers to the anterior region closer to the side of the eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in heel pad fat injections. I had a bad experience with an inexperienced podiatrist. He had given me cortisone injections to the heel pad for fasciitis. Unfortunately the outcome made my condition worse and I have lost most of the fat pad in my left heel. I am very active person and to be left like this at 35 is very depressing. Is there any hope? I don’t know if this requires an orthopedic surgeon instead. Please let me know what you suggest.
A: I believe you are correct in that heel pad fat injections would be the best approach to your heel pad atrophy. The normally tight heel pad which is weight bearing is a difficult place for fat grafts to take. But fat is a natural graft material and between the fat cells, fibroblasts and stem cells it is likely that some heel fat pad thickness restoration can be obtained. For many heel pad problems, it is surprising that more podiatrists do not embrace the use of platelet rich plasma (PRP) and fat injections. These tissue extracts from patients offer a more natural approach to many pain and tissue inflammation problems without any of the side effects of steroid injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about orbital asymmetry surgery. I suffered a zygomatico-maxillary complex (ZMC) fracture six months ago and have since had noticeable asymmetry of the orbits. The right orbit (injured side), is now noticeably higher than the left orbit. The right orbit was slightly higher than the left prior to the injury, but not to the current degree seen in the attached image. The medial portion of the eye is at an upward slant compared to the left eye which is more level.
A: Such orbital asymmetry would suggest an impaction type ZMC fracture. This could create an inward translocation of the inferior orbital rim/zygomatic body. This would then cause a buckling of the orbital floor upward, creating the changes you see now. But the etiology of these changes is best assessed by a 3D CT scan which would clearly show whether any asymmetry exists between the two orbital floors. If orbital floor asymmetry exists then lowering of the raised part of the orbital floor may be beneficial as an orbital asymmetry surgery. This could be done through a lower blepharoplasty incision to allow complete access to the entire orbital floor.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom skull implants. I have a flat back of the head and forehead. I have attached one photo in which I have pushed my hair down to show the depression on the back of my head and additionally on my forehead which slants backwards. I want a more symmetrical back of the head and and a more rounded forehead. Additionally I have added an edited picture which shows my desired results. Would these be possible with an implant? Finally I would need a ball park figure for the forehead and the back of the head surgery so I can figure out when I can go through with it. Thank you for taking the time to read this.
A: Both the flat back of the head and forehead can be augmented by custom skull implants. Your edited pictures show a back of the head augmentation which is just a bit bigger than what can actually be obtained with a one-stage custom skull implant. The realistic result is about halfway between where your are now and the ideal result. The limitation is in how much the scalp can safely stretch over the implant. For the forehead, however, that is a very achievable result as you have drawn it. My assistant will pass along the cost of the custom skull implants surgery to you next week.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I am a male and I would like to know whether it is possible to increase the slope of the forehead given that the thickness of the frontal bone allows for it. I have high temples, so the roundness of my forehead is displeasing to me. While my forehead does slope backwards slightly it is quite round, whereas I would like a ‘sharper’ look. Thank you for your time.
A: Your forehead augmentation desire is possible and would be best done by a custom forehead implant made from a 3D CT scan of you. This is the best way to get the angularity and sharpness in the implant that would be needed to create the outward forehead effect. The limiting factor in any forehead augmentation procedure is not the thickness of the frontal bone but the stretch allowed by the overlying forehead skin and soft tissues. I have yet to see this potential soft tissue limitation, however, be an issue in any forehead augmentation procedure that I have ever done. Most forehead augmentation needs rarely exceed 10mms in thickness and are often less than that amount.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I’m having a LeFort 1 and bilateral split sagittal osteotomy to widen my upper arch and move it forward and rotate it clockwise and to straighten my lower jaw, and correct an underbite. But since I’m going through the trouble of this surgery and its difficult recovery, I’ve been thinking about how I might as well make the results better. In an ideal world, I’d love to have a more prominent and masculine jaw angle and jaw line. My surgeon is considering combining the surgery with a sliding genioplasty. From what I understand, together these surgeries could improve my chin but not necessarily my jaw angle.
My two questions are: 1) have you had any patients who had a wrap around custom jaw implant (or even just jaw angle implants) done at the same time as a LeFort/BSS osteotomies? and 2) how long would one need to wait after surgery before considering implants? Thanks for your help.
A: It is not advised that a wrap around custom jaw implant be placed at the same time as a sagittal split mandibular ramus osteotomy. Placing a custom jaw implant over a newly made sagittal split osteotomy site may adversely affect bone healing. One should wait six months after orthognathic surgery to consider placing a custom jaw implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been bothered as I’ve aged that I’ve lost the ability to show my teeth when I smile. Would you recommend any lip procedure to improve this, considering I already have a short upper lip and would likely not be a candidate for a lip lift or an internal lip lift? I was also curious regarding the suggestion of a mucosal or vermilion-mucosal reduction to someone on RealSelf. Thank you for your time and consideration.
A: If tooth show is the main perioral aging issue and a subnasal lip lift is not an option, then a horizontal vermilion smile reduction would be an option. If the maxilla came forward in an orthognathic procedure that would also improve the amount of tooth show. But removing a strip of vermilion at the lower edge of the smile line is the most effective method to expose more upper tooth show.
But in looking at your pictures, particularly when you smile, you actually have an upper lip deformity known as a double upper lip. This is an excess roll of mucosa that hangs down significantly when you smile and the upper lip is stretched out. Resection of the redundant or excessive upper lip mucosa is what is needed for a double upper lip reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Two years ago, I had a septoplasty procedure with turbinate reduction due to a diagnosis of moderate sleep apnea. It turns out my septum was severely deviated, essentially blocking air at the back of one nostril. Shortly after surgery, I could breathe and smell things much better. Soon thereafter, everything has returned to pre-operative functionality, if not even worse. The surgeon I went to is an ENT physician, and refused to do rhinoplasty. I was advised by physicians later that a rhinoplasty procedure likely would have improved my nasal function significantly, simply by lifting the tip slightly. Would I be a candidate? I am concerned, because others have told me it’s a jaw issue and I would need orthognathic surgery.
A: The rhinoplasty procedure that you refer is two-fold and relates to the only two external (outer) nasal procedures that are known to improve nasal airway flow, spreader grafts of the middle vault and tip rotation. While both may be able to improve nasal airflow I would have no confidence that they would substantially improve sleep apnea. The only facial procedure that can reliably improve sleep apnea are jaw procedures that pull the face forward, particularly the lower jaw with the attachment of the base of the tongue, to open the posterior airway. But given the magnitude of orthognathic surgery it is understandable why other effort (nasal surgery) may be on interest to explore first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a facelift done while I am in surgery for removal of my thyroid. i would also like to have my breasts lifted. It would seem to make the most sense to do all of these procedures at the same time.
A: Understandably the concept of combining a facelift, breast lifts and a thyroidectomy would seem to make the most sense from a surgical and recovery efficiency standpoint. And to a large degree it is. However, the hurdles to overcome to put this surgical combination together are substantial. The first is to check with your thyroid surgeon to make sure he/she would be comfortable in doing so. Plastic surgeons are comfortable doing a large number of procedures at the same time, but many non-plastic surgeons are not. Then there is finding the surgeons who are willing to do so and have their schedules find a mutual operative date. Equally, if not more importantly, then there is the cost of trying to do cosmetic surgery in a hospital where the thyroidectomy would almost assuredly have to be performed. The costs of cosmetic surgery, such as lengthy procedures as a facelift, in a hospital are often substantially higher than what they would be in a outpatient or private surgery center. These hurdles are not impossible to overcome but will be challenging. It may be far easier to have your thyroidectomy done first and then the facelift and breast lifts done separately days to a week later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery for waistline narrowing. I am 30 years old, 5’2” 135 lbs with a 29 inch waist. I have breast implants and have had 2 fat transfers to my hips and buttocks. My waist may look smaller in these photos because I have added fat to my hips. When I was at my thinnest (125lbs) my waist was 26 inches. I feel I naturally have a very wide upper body. If I do proceed with the rib removal, am I obliged to wear the corset 24/7 for the rest of my life as I saw someone on TV doing? Any chance this would affect future pregnancies?
A: Rib removal surgery does NOT require wearing a corset or any form of wrap around support beyond the initial healing period of a few weeks after surgery. (because it will feel better if you do right after surgery) The patient and TV episode to whom you refer was waist training and that involves the long-term use of a corset. That is the exception and not the rule in rib removal surgery. This surgery would not affect the ability to get pregnant or carry a baby to term.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had this jawline augmentation morph done by a person who claims to do plastic surgery morph predictions, and I was wondering if this really is realistic and if I can look like this by any surgery necessary to achieve it. It is basically my ideal result if I could get it, but I want to know if it really is possible. (if anything, i would like to go even further)
Also, and this may be a bit ‘out there’, but would it even be possible to find a man with great facial bone structure and get him to get the 3D CT scan, then you can match my facial bones and jawline with his to make the implants so I would have a jawline augmentation to look like him afterwards?
A: I do think that type of jawline augmentation result is possible. It can only be done with a custom jawline implant designed by a surgeon who has done a lot of them who would know the dimensions to make that type of ‘extreme’ jawline augmentation result. It is not realistic to use someone else’s 3D CT scan as there are other factors involved in how one looks than just their bone structure. And no one is going to expose themselves to radiation for someone else’s benefit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very excited about finding your webpage, discovered by searching for ways/methods to remove/hide my two bulging temple veins/arteries. They are very prominent, especially when in the sun, after exercise, after an alcoholic beverage, in a hot room, or after a salt-enriched meal. Been dealing with these for 15 years and I am ready to just pull them out. I am bald and shave the rest of my head, so their prominence is highly noticeable and “causing a complex” doesn’t begin to describe the frustration and discomfort in my life . After seeing the explanation of the temporal augmentation process, with the photo of the man’s head with the incision and implant on is temple, I have a few questions. I am curious if the temporal augmentation implant can be placed in between the temple arteries and the skin? Thus putting a shield over the vein and permanently keeping it masked to never be seen again. If yes, you have answered my prayers. If yes, how big is the incision? Thank you for any information that can help me.
A: In eliminating or decreasing the appearance of temporal arteries, you can not put any implant between them and the skin for a number of reasons including risk of arterial rupture, visibility of the implant’s outline through the skin and the length of the incision needed to place them. In theory one could use that ‘camouflage’ approach with fat injections but I doubt that would be very effective and would create its own lumpy appearance issues. The proven treatment for prominent temporal arteries is multiple point temporal artery ligation that is done through several very small incisions. Temporal artery ligation is a procedure done under local anesthesia in the office after tracing out the pathway of the prominent temporal arteries.
I would need to see some pictures of your prominent temporal arteries to see if temporal artery ligation would work for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been saving up to have you perform a cranioplasty using custom skull implants to correct some asymmetries in my skull. When I was reading through your previous cranioplasty cases, I noticed you mentioned that typical PMMA implants could not extend past the superior temporal line. However, in one case (65 yo male), it appears that the custom implants extended over the temporal line and sat over the temporalis muscle. Is this indeed possible? Does the implant sit above or below the temporalis? If it does sit above the temporalis, could this potentially cause insult to the muscle? Is the screw secured through the muscle tissue? I was a bit disappointed to learn that a true widening of the skull could not be affectively achieved via cranioplasty, however it appears that custom skull implants can indeed broaden the skull. Would you mind clarifying these few points for me?
A: As a general rule it is not a good idea to place PMMA over onto the temporalis fascia/muscle. The firmness of the material and the sharp edges can create a palpate implant transition area and be a potential source of discomfort. A custom silicone implant is different in this regard since it is a much softer material with a finer edge and does not cause any discomfort by being on top of the fascial/muscle. It is quite common with custom skull implants to lay on top of the fascia/muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a breast reduction question. Immediately after surgery when the dressings were taken off, my areola have a somewhat different size and shape. I know that my breasts will hange during the recovery period as the swelling goes down. I was wondering if my areolas would also change in shape and size as well? I knew there was a high possibility of them being different but I wasn’t sure if they just look a lot different in size now because they are still healing.
A: The areolas may change a bit but not a whole lot as the breast reduction heals. Areolas are usually a bit different after breast reduction surgery because they were not never really symmetric initially. While they are cut evenly using a ‘cookie cutter’ at 42mm in diameter during the first step in breast reduction surgery, the act of sewing them back to a new spot on the breast mound and the suturing rarely makes them as symmetric as the way they were initially cut out. I would wait six months and if the areolar size and shape is still an issue, adjustment of them can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you please tell me if you perform buccal lipectomy and if so, how many he has performed? Thank you.
A: I have performed well over a 100 cases of buccal lipectomy procedures in the past twenty years. A buccal lipectomy surgery is very straightforward and uncomplicated to perform. There is no real risk to performing the procedure and I have only seen one infection in my 100 plus cases. (1% infection risk) I have not seen any cases of buccal nerve injury.
The key to a successful buccal lipectomy is one of patient selection. Determining who will and who will not benefit from the external facial change that the procedure can create has both short and long-term implications. The concern today with a buccal lipectomy is that it may result in facial gauntness as one ages. Since facial fat is lost as one ages, removal of the buccal fat pads in youth can result in a sunken face look decades later. This is why it should be only considered with caution in younger leaner people. It is ideally best done for patients that have fuller rounder faces who appear to be genetically predisposed to a natural rounder face
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wondering if you can help me…. I’m currently exploring my options. I have recently inquired about what surgery can be done to reduce the width of my head. Other doctors have suggested Botox and also an earfold treatment to pin my ears back. I’ve noticed on your site you do temporal reduction by removal of muscle. My hairline is thinning and I’d be concerned about the scars. A lot of the my width of my head is the muscle as I can move it upwards and see a huge change. I’ve pasted an extraction of part of your website… is this actually possible to do it from an incision behind the ear? I’ve attached a picture for you to review.
A: The most effective and quickest method of narrowing the sides of the head is a temporal reduction procedure where the posterior belly of the temporalis muscle is removed. While I initially developed the procedure using a small incision in the temporal hairline, more and more patients over the years who shaved their heads or had close cropped requested the temporal reduction procedure. It became necessary to find a completely ‘scarless’ way to do the temporal reduction procedure. Just like inserting temporal implants to widen the head, a temporal reduction procedure can also be done through a postauricular incision that sits right in the crease at the back of the ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I previously had a mini direct neck excision with a horizontal chin scar and a vertical scar extending about halfway to the Adams apple. I am 54 years old and had this procedure done to deal with loose skin from a previous chin reduction done ten years earlier. Is it possible to update this procedure into more of a direct neck lift? Is it possible to extend the scar a little more vertically to take up some lower neck slack?
A: Since you are already have partial direct necklift scars, there would be no reason why you could not extend the vertical portion lower. The lower end of a direct necklift is very effective at tightening loose skin above the adam’s apple. While it can be technically done, the only issue to be considered is how well the lower end of the direct necklift will do. In younger skin this lower end of the scar may not heal as well as the scars directly under the skin. While the risk of significant hypertrophic scarring from the lower end of the a direct necklift is low, it is a potential issue to be made aware.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young male (27 years old) who is self-diagnosed with sagittal craniosynostosis. I want to have sagittal crest reduction by a significant amount. (approximately 1.5cm) I know sagittal crest reduction is possible up to a maximum of 7mm. But if you suffer from sagittal craniosynostosis isn’t it logical to think that there is more sagittal crest bone and therefore more to reduce?
A: In reality, having a sagittal crest from a limited form of sagittal craniosynostosis may or may not make the bone along its midline length thicker. That speculation can be answered by a CT scan in which the bone thickness can be directly seen and measured. However, I doubt very much the bone is thick enough that would allow a sagittal crest skull reduction of 15mms. Having done many sagittal crest skull reduction procedures, I have not found them to be extraordinarily thick or substantially thicker than that of the surrounding skull bone. Usually they are in the order of 5mm to 7mms thicker before the inner cranial table is seen and/or violated.
When one thinks they need as much as over a centimeter of sagittal crest bone skull reduction done, they may likely be suffering from a parasagittal deficiency along side the sagittal crest as well. In these cases the best treatment is a combined sagittal crest reduction and bilateral parasagittal bone augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a glabellar implant. My interest in glabellar augmentation is that as I have had rhinoplasty and fat graft to forehead but my glabellar region is flat in comparison. I would be interested in knowing whether it looks natural when raising eyebrows and facial movement? Is there a visible border from the implant? Also what is the recovery time?
A: While glabellar augmentation can be done by a variety of materials and techiques, the most successful method is a custom glabellar implant made from the patient’s 3D CT scan. Since the glabella is a broad-based region that is like a diamond shape, it is best to have it custom made so that it blends smoothly to the surrounding bone and would have no visible or palpable edges. It is placed in the subperiosteal plane from an endoscopic scalp technique so it does interfere with any eyebrow or forehead movements. The glabellar implant is placed through a small scalp incision after the subperiosteal pocket has been made using the endoscope. The recovery time is very quick with limited swelling that should largely be resolved in a week after the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Perioral mound liposuction. I received Perlane to the corners of of my mouth and they have never been the same. I know the product is gone, but nonetheless the bulges remain. I do not know if they are fat, scar tissue or simply excess soft tissue, but I have these convex mounds on either side of my mouth which are less than attractive. I hate them and want them gone. They age me more than any other facial area.
A: Thank you for sending your pictures. Despite your lean face you do have very discrete convex mounds at the sides of your mouth. I could not tell you what composes them or how effectively they can be eradicated. But I do know that the only procedure that has any chance of reducing them would be small cannula perioral mound liposuction. This can be performed under local anesthesia or IV sedation. This is a small procedure that has a short recovery. Because of swelling and the small size of the perioral mounds, perioral mound liposuction can take several months to see the final result. I will have my assistant followup with you tomorrow to pass along the cost of the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I want to change the shape of my face. I have a long and thin face which I do not like. I have attached pictures of model faces that I do like. I can not really tell what is different about them from mine. I just can’t point my finger on what it is or what I need for facial reshaping surgery.
A: Thank you for sending all of your own pictures for consideration for facial reshaping surgery and that of faces that you like. All of the faces you like the same differences from yours…their cheeks are much fuller and wider, the chin is vertically shorter and they have more pronounced jaw angles/width. Your face, attractive as it is (although not to you) is longer and thinner. Your ideal face is wider and shorter. To make your face more like your ideal the following three facial reshaping procedures would be needed. Cheek augmentation using implants to substantially widen and increase the apple cheek effect. Your chin could be made vertically shorter by an intraoral vertical reduction bony genioplasty. Thirdly, jaw angle implants would be needed to widen your jawline. The facial reshaping change you seek is… long and thin to shorter and wider.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a general question regarding jaw angle implants. I’m currently trying to decide whether to choose silicone or medpor material for jaw angle implants augmentation. I’m trying to create sharp, square, chiseled angularity more than just adding width. I’m getting differing opinions whether silicone is able to do this as effectively as Medpor. I’d really like to go with silicone (particularly a custom silicone implant) due to ease of removal and no tissue ingrowth, but I’m worried the result would be less angular and more soft, such as in the photo I’ve attached (notice how it’s more of a U shape than a sharp V). I’ve read some claims that because Medpor is a harder, firmer material, it creates much better angularity for those seeking a sharper jawline. Basically my question is, if I were to opt for a custom silicone jaw implant, would it able to create just as sharp jawline edges as Medpor material would, or will silicone always looks a little softer?
A: The answer to your question about jaw angle implants is two-fold. First, regardless of implant shape, not every patient has a good chance of developing a sharp angular jawline. The only patients who will do so are those with thinner lean faces with little fat. Men that have fuller and rounder faces with more fat will fail to develop much definition. (as illustrated in the example you have shown) Thus one’s own tissues must be taken into consideration. Second, your selection of a silicone material for jaw angle implants would be best in my experience for the reasons you have mentioned. But the only assured way to get the most angular result is to have the implants custom made. Otherwise you take your chances with performed jaw angle shapes and sizes. As an aside the slightly firmer feel of Medpor does not give it increased angularity. It is the implant’s shape that determines the external change not the implant’s material composition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two abdominal surgeries. The first was a hepatic bypass and the last one was a partial hepatectomy. My last surgery was complicated with infection at the organ level as well as an incisional hernia. The surgeon plans to surgically repair the hernia in May or June of 2016. I am interested in having a tummy tuck at the same time. I am not sure if I am a candidate or not. Would need to know if the two surgeries can be done at the same time.
A: The question you ask about a concurrent tummy tuck done at the same time as an abdominal wall reconstruction (hernia repair) is determined based on the consideration of multiple issues. First I would have to see pictures of your abdomen to determine the tissue excess and the location of your current abdominal scars. The location of certain abdominal scars may preclude or at least potentially complicate healing of the tummy tuck incision. Secondly, you would have to be in good medical health (which I would assume you would be for a hernia repair), on no immunosuppression drugs and be a non-smoker. I would need to know more about your medical history. Lastly there is the economics of doing a cosmetic surgery procedure in a hospital. While many patients think that most of the cost of the surgery would be covered by insurance because one is already asleep and having surgery, that is not the case. Hospitals are well aware of what is being done and will hold the patient accountable for the time and costs of the tummy tuck surgery, including OR costs and anesthesia, up front.
Dr. Barry Eppley
Indianapolis, Indiana