Your Questions

Q: Dr. Eppley, Hello. I had a large chin implant placed 4 weeks ago. I believe it is too large/high. I also can not smile. Would you recommend replacing the implant? I included some before pics for reference. The collage are all before pics, just some are from when I was younger. Thank you for your time. I wish I had found you 4 weeks ago! 

A: Thank you for your chin implant replacement inquiry and sending your pictures. While your chin was naturally short/smaller, it is a ‘compressed’ type of short chin which means there is a vertical component to the chin deficiency as well. (as evidenced both by vertical facial third assessment and the deeper labiomental fold) Your chin implant may or may be too high but when just horizontal advancement is done in a chin like yours, the vertical shortness becomes magnified…and you have all of the symptoms that you describe. While chin augmentations do take a full three months to see the true result, I would agree that the symptoms you have now both aesthetically and functionally are not going to substantially improve. You really needed a 45 degree type of chin augmentation in which the vertical lengthening with less horizontal projection is the more appropriate dimensional change. Your current implant relies exclusively in the horizontal projection to achieve its effects…which in many patients is fine but it just doesn’t work well with your chin anatomy.

Your options now are:

1) Remove and replace your chin with a small vertical lengthening style which produces a 45 degree type of projection. (5mms forward and 5mms down)

2) Remove the chin implant and replacement with an opening sliding genioplasty with the same type of dimensional movements as #1 option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orbital rim implants six weeks ago along with a canthoplasty, but I believe they are too big for my very small face, and created a concave shape in my cheeks below the implant. Are there custom implants that would look good on a small face? I am a small built female with a very narrow face.

A: Thank you for your inquiry and detailing your recent surgery. Once of the ‘advantages’ of having implants in place and knowing what you don’t like about them is that it makes designing a new implant that works better much more likely. (i.e., when you know what doesn’t work that helps considerably in figuring out what will work) Beside the size issue one of the disadvantages of preformed implant shapes is they are made for a skull model and not your specific anatomy. This is why the transition between the implant and what lies around or below it is obvious now that the swelling has subsided. Custom implants solve/improve that issue by their design in most cases. A preoperative 3D CT scan nay also reveal any other reasons (e.g., positioning) as to why you see what you see on the outside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your reply!. Alloderm seems to be a great option!. For the measurement of the shoulder atrophy, it’s very asymmetrical and not a perfect round shape. So this area (of skin atrophy / fat atrophy) is around in height 8 – 10cm and in width around 5-6cm (sorry its hard to measure it) It will be so amazing and my dream if i can find a permanent solution, and feel normal…

After alloderm graft, will the result be permanent? Like if for example i lost weight, do sport, or get old?. And I have heard that Alloderm can be resorbed over time, is that true?

Thank you so much for your kindness!

A: Thank you for sending your measurements. The purpose of the measurements is help select what size Alloderm or Strattice sheet (both are tissue bank dermal grafts) is needed or what the dimensions of the implant would be if we where going that route.

My extensive experience with Alloderm in the face as well as the breast is that it is volumetrically persistent. Whether that translates to the shoulder for your type of problem can only be speculated as who has ever done it before? Alloderm is used extensively in breast reconstruction as a lower sling to support an implant and as a reinforcing sling in aesthetic breast surgery for bottomed out breast implants…situations where its persistence is important. Whether the high motion area of the shoulder will share a similar long-term outcome is presumed. While a custom soft silicone implant will undoubtably provide long-term volumetric maintenance my long-term concerns with its use in the shoulder is eventual edging of the implant being seen and/or an unnatural folding of the implant when you raise your arm., Thus it is better to have something that will allow tissue ingrowth and a few less risk of graft edges being visible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, my concerns are a very asymmetrical nose from a prior rhinoplasty. I have been afraid of redoing it through the years and having worse results, but as I age, it becomes more and more obvious to me. I also have concave temples (I once had a blend of heart shaped/oval) but now have a peanut like facial shape, with my left eyebrow sagging worse than my right one. I also notice it increases the sagging of my outer upper eyelids, so when I relax my facial features I look grumpy or unhappy when I’m not at all! 

I would like these two issues for sure. Id like to have more addressed but my nose and my temples are my highest priority, I’d like to find out how expensive they may be, including a generalized idea of How extensive would my nose repair might be? I have hanging columella and alar retraction for sure. I am not looking to have the “perfect nose” but I would like it more symmetrical and when I use my muscles to pinch my nose downward and push up on the columella it looks so much better with allowing my eyes to be more visible (except for the alar retraction is also still visible with pig-like nostrils lol.)

I am a medical professional so I fully admit I’ve researched all the procedures and watched several informative surgical videos of these procedures, as well as multiple reviews of surgeons across the country. So I am most interested in the cost and the potential of how extensive these procedures might be for my situation and how much vacation time off from work I’d be required to have. Thank you so much for your time!

A: Thank you for your inquiry, sending your picture and detailing your concerns. From a primary standpoint the permanent treatment of temporal hollowing are temporal implants. Like many women you need the extended design and the only debate is what thicknesses they should be. (4 and 6mms are the options of which most women usually get 4mms) For your revision rhinoplasty based on your picture and description most if not all of the issues are in the tip area. It appears that it is a combination of hanging columellar correction (caudal septal resection and columellar strut), alar retraction correction (alar rim septal grafts), and tip defatting/scar removal and possibly some tip rotation. My assistant Camille will schedule  a virtual time to discuss further if you would like as well as pass along the cost of such surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve provide the list of items below that are related to the asymmetry of my face:

1) Uneven eyes (Might be worth noting that it seems like the older I get, the worse it gets.)

2) My jawline is uneven.  It might be difficult to tell in the image, but one side of my jaw is not symmetrical to the other side. If I lost about 10 pounds it would be more evident.

3) I’d assume, that if my eyes were to be re-leveled, it might also require some adjustments to my nose since its alignment appears to coincide with the asymmetry of my eyes.

4) Lastly, if I decide to undergo any procedures related to my eyes, then it is probably also worth considering doing something about the bags under my eyes that give the appearance that I am always tired.

If you have any questions or I need to provide further information, please let me know.

A: Thank you for your inquiry and sending your pictures. You have an overall right facial asymmetry in which all the facial features on the right side are different. (smaller/lower) Some are very minuscule but they can be seen when looked for carefully. (which you the patient has) Yours is a superior facial asymmetry where the greatest and most visible difference is at the eye level. (vertical orbital dystopia = VOD) Think of the eyes like a box (hence the name orbital box) where the eyeball is encased in a box of bone. Thus in your right VOD the orbital box is lower. Hence not only is the eye lower but what lies around it is lower as well. (eyebrow, brow bone, upper and lower eyelids, cheek) This is noteworthy when treating VOD as pushing the eye up is one thing but how does that affect the appearance of what surrounds it. (meaning you can’t usually just push the eye up in VOD and get a complete correction)

The first place to start to determine what and how to do it is to get a 3D CT scan for full assessment. I will have my assistant Camille contact you to schedule a virtual to discuss in more detail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. The main reason is mostly cosmetic so I would also be looking into liposuction in that area as well. I am of a smaller build 5’2” 118 lbs. The asymmetry in my body and lack of waist has significantly impacted my body image so I have been looking at rib removal for years but always thought it was too dangerous or extreme! 

I am curious about how much greater the risks are in regards to the organs once the ribs are removed and with my scoliosis if the risks are higher?

A: The risk of organ damage in general in rib removal surgery is essentially zero. It is a common misconception that is a concern. I would refer to my website, www.exploreplasticsurgery.com where you search under the term RIB REMOVAL and read what I wrote about Rib Removal surgery and organ damage in an article in more detail. This is particularly relevant in your case where taking rib #12 has no aesthetic benefit. You will understand the relevance of that when you read that article. Your scoliosis creates no added risks to the surgery. Its only relevance is that it has shown on one side why taking rib #12 has no benefit to waist reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m on your page now for the surgical reshaping of a flat back of head? I hate the shape of the back of my head and am willing to travel for this. I also saw your comment on a Real Self question & answer forum saying that this procedure can be done non surgically by injection… could I please learn more? Namely how much would these cost? 

A: To clarify on augmentation of the back of the head, the superior method aesthetically is a custom skull implant. For smaller skull shape defects PMMA bone cement can be used through a very small incision with introduction with a funnel…but that is not a ‘non-surgical method by injection” It is still a surgical procedure that requires the same dissection under general anesthesia as placing a custom skull implant. It also does not produce as good an aesthetic result. You are over interpreting what you have read.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could suggest me what you would do to improve my appearance. I have an asymmetrical jawline, which is more visible when I smile or talk, but at the same time I feel like my face could benefit from other surgeries as well. (my forehead is prominent, my eyes are sunken) I do not know which surgery I would benefit the most from. I am only 26 years old and I feel like I look older, and I would like to go and correct what could cause me to perceive myself that way.

 I would really appreciate your feedback.

A: Thank you for your inquiry and sending your pictures. The one surgery that would benefit you the most is the one that treats the single feature that bothers you the most…which only you can say. You have listed high forehead, sunken eyes and asymmetrical jawline. The reason you look older has to do with your sunken eye appearance with a touch of upper eyelid ptosis. Unfortunately that is also the one facial feature that is the most difficult to improve and even more difficult to try and image the change on your picture. For the sake of discussion I have imaged hairline advancement, rhinoplasty and left chin-jawline augmentation. Then in a second image I added some slight volume to the inferior brow bone/upper eyelid area and even that small amount to ma made a big difference in improving that facial issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a few photos. Looking to advance the chin a bit, remove some of the fat surrounding the neck and perhaps have implants or filler to give the lower mandible some form. My under eyes are also quite hollow so I would be interested in looking at solutions for that. 

A:Thank you for your inquiry and sending your pictures. I did some initial imaging on the side view one which is the best place to start with an initial assessment from which I can make the following comments:

1) With your thicker facial and neck tissue, and naturally shorter lower jaw, what I would recommend is that you first work on the chin-neck relationship  and gets some positive changes there. With your shorter neck and thicker tissues a sliding genioplasty is a better chin procedure for you as moving the chin bone forward pulls the neck muscle out which is a big help in the thicker neck patient with an obtuse cervicomental angle. This can be combined with a submentoplasty procedure to remove neck fat and tighten the platysma muscle to really help your cervicomental angle. These two combined procedures will do the most for your chin projection and neck reshaping and then you can see about any further work on the rest of the jawline later.

2) Your undereye hollowing could be done with the chin-neck work and is going to require a custom infraorbital-malar implant to give the undereye area the added volume that it needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How much vertical chin reduction can be achieved in my case by the intraoral wedge removal genioplasty?

A:Thank you for sending your chin pictures. While I haven’t yet seen a panorex x-ray to yet determine how much chin bone can be safely removed, I can predict at last 1 cm of vertical bone height would be reduced in the center. (which by definition has to taper out to the sides) But the real limiting factor in how much vertical chin reduction is seen on the outside is the overlying soft tissue which is obviously not removed. It can be compressed somewhat as the chin bone is vertically shortened but not in a 1:1 relationship to that of the bone removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant revision surgery 6 months ago. During the recovery, the nerve reaction on the right side is slightly weaker, causes no problem. I believe there should not be any nerve injury during the procedure. 

However, intermittent numbness and pain become more severe in the latest month. The implant was perfectly screwed and didn’t shift. I found one possible reason is that one side of the incision (denoted in green color in the attached photo) is close to the mental foramen. As the underlying scar grows, it may compress the mental nerve, which causes the pain and numbness (sometimes an itchy feeling). These feelings become stronger if I pressed the skin above the mental foramen. 

Could this develop into chronic pain? Is that possible to deal with this by nerve decompression surgery someday later? 

I’m looking forward to your reply!

A:It would be impossible to predict how the affected mental nerve may react as its distances itself from the date of the surgery. But at 6 months out from the surgery it would seem not very likely to develop into chronic pain if it has not done so already since the scar tissue has fully formed at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Hello, a couple of questions. I’m planning on getting perioral mound liposuction, mouth widening surgery, a dermal fat graft into my labiomental crease, and maybe a buccinator myectomy (if needed) I’ve already had around 85% of my buccal fat removed so I dont need anymore removed. A couple questions I workout so I fluctuate in weight by roughly 20 pounds depending if I’m bulking or cutting. I gain slowly (roughly half a pound a week) I was curious would gaining/losing weight effect the perioral mound liposuction? As in would it come back if I gained a bit of weight? As well as would the fat graft in my labiomental crease get smaller/bigger if I gain/lose weight? Also, I’m going to he getting a genioplasty at some point mostly vertical movement and maybe 2 to 3mm forward movement would it be best too get the fat graft in the labiomental crease after that procedure? Also how much would this is all cost? Sorry for so many questions! 

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

1) Since the perioral mound areas is subcutaneous fat and not really a typical fat depot area, it should not be affected by the weight gain that you have described.

2) The injection fat graft is a more relevant one for the concern about it changing with weight gain or weight loss particularly if the abdomen is the donor site. Which is why the inner thigh should be used as this is not a typical fat depot site.

3) Whether you do a labiomental fat graft during or after a primarily vertical lengthening genioplasty is irrelevant from a technical standpoint. It is more relevant from the effects of the genioplasty as vertical lengthening genioplasties tend to lessen the natural depth of the labiomental sulcus. So it is possible you may not need anything done to the labiomental sulcus based on the effects of the lengthening genioplasty. This would be the argument to wait and see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, 1. How would my face look smiling? That was something I forgot to ask during our 10 minute consultation and something the retouched images from your initial e-mail reply didn’t show. Is there any way to predict, or responsibly hypothesize what I’ll look like smiling after implants?

2. This is probably a silly question, but you said custom implant recipients tend to be more prone to wanting revisions. Do we live in such a world that if I’m not satisfied with the end results, costs are waived for revisions or implant removal? If so, what waived costs or discounts are offered?

3. I like to think catastrophically sometimes to try to be as prepared as possible, so bear with me on these next few which get a little dark. What happens if I’m in an accident after surgery and break bones where I have implants? Would I need to have them removed and have you to re-do them after the bone was mended?Are there activities I’ll need to avoid to ensure the implants don’t shift or break?

4. This one gets a little darker so I apologize in advance and hope you see my intent comes from a good place and the desired to think ahead and be prepared: Okay, let’s say we’re halfway through implant design or maybe I’ve gotten the implants and I’m happy with them but something happens and they need to be repaired but you’ve either retired or gotten struck by lightning or, for whatever reason, just aren’t available. Do you have a rolodex of surgeons you trust to do these surgeries just as well or better than you? If so, who are they? Even though it wouldn’t be particularly self-serving, is there anyone who you feel could do these implants just as well or better than you?

Thank you so much for taking the time to help me learn as much as possible before I start this journey with you and your team! I really appreciate it.

A: In answer to your custom facial implant questions:

1) I have not yet had any issues in facial animation with infraorbital-malar (IOM) or jawline implants. The only potential issue with smiling would be with the IOM implants. But because they are in higher position than standard cheek implants they are more out of the way when the cheek tissues bunch up with smiling.

2) This is a very important question and I would ask my staff about that very issue for which there is a revisional surgery policy. It spells out the risks and the patient obligations should that occur. Such revisions are not what I want but when you put implants anywhere the body that risk is very real and not insignificant.

3) The issue of trauma to the implanted site is a common question. The reality is that it has never yet occurred or one in which no patient has ever had an actual scenario as you have described that has been relayed to me. From a trauma standpoint custom IOM and jawline implants are like putting bumpers on the bones. It would be very hard (albeit not impossible) to fracture the bones underneath them. In essence they are like shock absorbers.

4) Admittedly a bit darker but not a completely impractical question. There are other surgeons in the US who do perform these surgeries. It is a very small number but they exist. Most are not going to have my experience in designing or perform these surgeries. I can not tell you whether any of them are poorer, as good or better than me at it, regardless of their experience since there is no assessment method to make that comparison.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was curious generally speaking what percentage of people have the type of skull shape which would accommodate a 1 inch implant for cosmetic stature gain in an aesthetically pleasing manner, and what that ideal skull shape is. 

To be candid I was surprised to find that this is even done, because my first instinct was to assume that such an implant would look unnatural, like something from Star Trek or Coneheads or something. Is it the case that average skull height is variable enough throughout the population that such a change is easily concealable? Does the size of one’s forehead or their hair type or any other factors significantly affect one’s suitability for the height increasing procedure with respect to concealment? 

I feel like there are two bifurcated philosophical schools when it comes to cosmetic surgery patients – those who don’t mind a slightly (or significantly) unnatural look, which perhaps represents the vanguard of cosmetic augmentation, and those who want as close to a natural appearance as humanly possible. I would definitely place myself in the latter group and wouldn’t want anyone to wonder “what’s up with your head”? 

I was also curious what your opinion is regarding surgery on the scalp for patients with a history of keloids developing in common keloid forming areas. For example I have several keloids in my sternum area as well as my right shoulder, which apparently are two common areas, however I thankfully do not have any on my face. Could a small “test incision” be done on the scalp to make sure the area responds to trauma well before an actual procedure? 

Thank you for reading

A: Thank you for your inquiry. The key to all skull implants is that their design has to look like they belong there as a natural extension of the convex shape of the skull.  As a result they cover a much larger surface area than one would initially think to do so. And usually most patient’s way over estimate the thickness of the augmentation they need because they focus on a simple linear measurement rather than the volumetric effect of large surface area coverage. The limiting factor in any skull augmentation is the ability of the scalp to stretch to accommodate what is placed underneath it. In general most people can tolerate a 100 to 150cc implant without a first stage scalp expansion.

When it comes to what patients want, very few patients want anything but a natural looking result. One’s interpretation of what looks natural will vary as what one person deems natural may be unnatural to another. But in skull augmentation everyone wants a natural head shape result.

Trying to correlate how a scar looks on the body to what may occur on the face or scalp is not comparable. Most likely you have hypertrophic scars, not true keloids, which are common in many people particularly in the sternum (which is a terrible area for a scar) as well as the shoulder which is a high motion area with thick reactive skin. Making a test incision in the scalp is not replicative of the situation when an implant is placed underneath it with the incision subsequently closed under tension.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your reply to my son regarding further head width reduction treatment He is extremely happy that you are able to carryout further treatments to enable him to look and feel better about himself and therefore more confident.

There are a few areas I am unsure about and so would like clarification on please. Previously you mentioned two options 1. Botox and 2. electrocautery surgery.The advisory treatment offered to him is ‘Temporal Reduction Bilateral, Anterior, is this the electrocautery surgery? 

Is this the preferred treatment for Nic as opposed to Botox injections? I assume this option has been chosen as he would prefer a more permanent result.

As he has already had posterior temporal reduction and now planning anterior surgery will there be any possible adverse long-term side effects?

How long will the immediate recovery period be before he will be able to leave your care and carry on with his journey?

I look forward to hearing from you

A: While Botox will likely create improvement in the fullness of the anterior temporal muscle, it will not be permanent. The thermal treatment of the muscle results in eventual partial muscle shrinking/atrophy which is permanent. I have done such anterior reductions on patients who have had prior posterior temporal muscle removals and there have been mo adverse functional effects from doing so. Like the last surgery he will be able head home on a similar time frame. While the immediate postoperative swelling is very similar the effects of muscle atrophy take much longer to see than muscle removal. The muscle shrinks down over a period of months after the surgery so getting to the final outcome requires more patience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve wanted to get skull augmentation surgery done for a while, probably 3 procedures if not all together, the frontal, temporal and back of the head procedures and i was wondering what the cost would be. I don’t want an extreme change but to make my forehead a bit more round in shape and more prominent i guess and possibly near my brow bones or cheekbones too if possible. I was wondering if they’d have to be done all at once or not, what the cost would be etc.

A: Thank you for your inquiry. You are referring to skull augmentation in which you reference the forehead, temporal and back. Since the scalp will only permit so much augmentation to occur (unless one does a first stage scalp expansion), it is important to prioritize the areas of concern. Based on your description of your forehead /temporal objectives I would assume that is a priority area as it is also the most visible. That would be done as a combined implant in one surgery.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr. Eppley, I would like a forehead reduction procedure. My questions are:

1) is it possible to reduce the advance and the width of my forehead?

2) what is the waiting time to be operated?

3) how long do i have to stay during the operation in the USA?

I also know that a scar is visible after the operation.I was thinking of doing a FUE hair transplant procedure to hide this one and advance my front line. 

Do you think this is possible?

Best regards.

A: Thank you for your inquiry and sending your pictures to which I can make the following comments:

1) It is not a question as to whether your bony forehead can be reduced in both width and forward projection…but by how much. Bony foreheads can be reduced by removing the outer cortical layer of the skull down to the diploic space. How thick that layer is is what determines the magnitude of change. A preoperative CT is needed to make that determination.

2) if you want to undergo a hairline advancement this is best done at the time of the forehead reduction as the best place to put the incision is at the frontal hairline. That would achieve two goals at the same time.

3) You wouldn’t do a hairline advancement and FUE hair transplants at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have prominent temporals major muscles which are very strong. It bothers me in two ways: 

1) I get incredible tension headaches from clenching in the night and even eating chewy food. 

2) I dislike the look. 

I’ve had three Botox courses into the muscle to try and reduce it and whilst it provides some temporary relief it’s short lived. 

I’m interested in the surgery and wanted to understand more about it.

Thanks in advance.

A: Thank you for your inquiry and detailing your temporal muscle concerns. The critical question is which part of the temporal muscle is involved.  (posterior, anterior to both) That knowledge determines the extent of the surgery and time/cost to do so. Please send some pictures that show the event/location of your temporal muscle hypertrophy. Based on your description I suspect it is a combination of both posterior and anterior area temporal reductions which, although can be surgically treated at the same time, are done by different methods.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Im wondering on the cost of getting bone cement in my forehead to fill in the sunken in curves for a beautifully shaped forehead. Thank you!

A: Thank you for your inquiry. There are three materials in which to perform forehead augmentation including two types of bone cements (PMMA and hydroxyapatite) and a custom forehead implant. With each technique comes different costs and potential outcomes. You mentioned ‘bone cement’ but I don’t know if that is what you are interested in exclusively or that is the only technique in which you are familiar. Custom forehead implants always produce the best aesthetic results and are done through the smallest scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley: I have a Medpor chin implant. At three months post-op, I went to dentist for regular cleaning. However, my soft tissues are not fully healed with the Medpor chin implant at that time, and when the dentist presses my lips, I felt a sharp pain in my chin. I lost the sensation of my chin immediately. 

Now it’s about 4 month after the dentist visit, one side of my lip still feel kind of numbness. I guess my mental nerves are over-stretched by the dentist. Will the sensation of lip gets back to normal? How long will it take. Is it possible to have a permanent mental nerve damage by regular dental cleaning? Thanks a lot!

A:  I do not think it is possible that permanent nerve damage to a chin implant can occur from a dental cleaning.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about a breast augmentation and possible lift. I have sagging due to two children breastfeeding. I was told having a lift would make the sagging worse from a previous surgeon. How can we ensure this would not happen if I only did the augmentation?

A: Thank you for your inquiry. I have never heard of or can understand how a lift could make sagging worse if done with breast implants. It is the opposite which is certainly true….in the presence of sagging (nipples below the inframammary fold) the use of breast implants alone can make sagging worse. Perhaps you have pseudoptosis (nipples at the level of the inframammary fold but with breast tissue hanging below) in which breast implants alone would be adequate.

As you can see the type of breast sagging determines where a lift is needed with breast implants.

To determine what this means for you I would need to see some pictures of your breasts from the front and side for a more informed recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is tip reduction possible in this very thick skinned big bulbous nose tip?

A: Thank you for your inquiry and sending your picture. The question is not whether tip reduction rhinoplasty surgery can be done in your nose but whether the amount of improvement obtained would justify the effort. That answer would never really be known until the surgery was done and the outcome eventually seen. But the way to choose whether surgery is worth it up front, in a procedure where the outcome can not be accurately predicted beforehand, is the attitude one walks into surgery taking. If one says to themselves any improvement is better than what I have have…then surgery will be worth it But if one has a very specific goal (e.g., 50% reduction and a substantially thinner nose) and one feels surgery would not be worth it unless that was obtained than one shouldn’t do it.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I came across an article written by you about fat grafting to the chin for a deep labiomental fold. It is something I struggle with and was hoping to get more information about the procedure. Thank you.

A: Thank you for your inquiry and sending your pictures. You have a moderately deep labiomental fold for which fat grafting would be an appropriate choice to treat it. The debate is whether that is injectable fat grafting or the intraoral open placement of a dermal-fat graft. That question is best answered by how the fold responds to injectable fillers. If injectable fillers pushes it out nicely then fat injections would work. If it doesn’t push it out well due to tissue adherence then the release and open placement of a solid fat graft is best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am unsatisfied with how high my eyebrows are, and I feel like they make me look slightly feminine. When I furrow my eyebrows, they move downwards, closer towards my eyes, and become straighter, which gives me a more masculine appearance, as you will see in the image I’ve attached. Additionally, my eyes become slightly hooded as well, as the excess skin over my eyelids moves down. Overall, I am extremely pleased with this appearance, however, it is inconvenient for me to go around with my eyebrows constantly furrowed! 

That being said, I am wondering if there exists any procedure(s) (surgical or nonsurgical) that will give me the look I desire when I furrow my brow. I am currently considering a reverse brow lift, but I am unsure if it will produce the result I desire. Botox is also an option, but I am uncertain how far my brow will be able to move down. Will injections give me the look I desire? 

Also, please let me know if there are any other procedures I could undergo to achieve the desired look, no matter how expensive or unique. 

Thank you in advance!

A :The lowering of the eyebrows is a difficult tissue change to accomplish in a young person because of their tight forehead skin. Enough Botox may have a temporary effect  (3 months) but that is obviously not a long term solution. A reverse browlift is not going to work for the reasons previously described. (tissue tightness) The only way to lower the brows is with a supplemented reverse browlift using forehead tissue expansion. You must create the tissue stretch closest to where you want the effect. This is done with a specially shaped type of tissue expander

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about testicle enlargement. I have normally functioning albeit small testicles. I am curious if you have noticed any atrophy of the existing testicles with the implants? Any problems with sperm count after the surgery? 

Finally, would you let me know if you have any pictures of the implants and the cost of the procedure? 

Thanks.

A: Thank you for your inquiry. In answer to your testicle implants questions:

1) I can not speak to whether implants have any adverse effects on the existing testicles as no such tests have ever been done (e.g., sperm counts) nor has any patient ever mentioned any issues. I would assume it does not since the vascular supply to the existing testicles remains intact. Most of the men who get this procedure are often older where any concerns about sperm counts are largely irrelevant.

2) To see pictures of the implants I would go to www.exploreplasticsurgery.com and search under Testicle Implants where you will find many articles with implant pictures on this subject.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Are you put to sleep while the occipital bone reduction procedure is being done? & how long do you have to be out of work after the procedure is done.

A: Thank you for your inquiry. In answer to your occipital skull reduction questions:

1) You are put to sleep for almost all forms of skull reshaping surgery. These are not procedures to be done under local anesthesia or IV sedation.

2) Physical recovery is very quick from skull eduction surgery and you would be out of work at most one week after the surgery. The actual results, however, takes much longer to finally see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young African-American. man. I am looking into augmentation rhinoplasty. The concerns I have with my nose are its wide nostrils, bulbous tip, and low bridge, in order from most distressing to least. The internal structure of my nose is in great condition. I have no trouble breathing. My septum is in pristine shape, full of cartilage with no deviation. Cartilage grafting and an alar base reduction seem to be the best course of action. I am looking for a surgeon who can reasonably achieve what I’m looking for and do it affordably. I’ve attached pictures of myself below. I am asking that you provide me with a quote for the rhinoplasty procedure. I completely understand that without a physical examination you cannot give an exact quote, but I’m certain that the doctor or director can give a reasonable price range based on the information I have provided.

A:Thank you for your inquiry and sending your pictures. You have clearly outlined your rhinoplasty needs/goals of which augmentations of the dorsum, tip narrowing and elevation and nostril reduction are the cornerstones of it. The key issue in any augmentation rhinoplasty is what type of material does one want to use to do for the building and how much of a build does the patient want or need. For the tip of the nose septal cartilage is always used for the columellar strut and onlay tip grafting, there is not any debate at this augmentation area. It is the bridge (dorsum) where the discussion lies.

The bridge can be built up using three types of materials, septal and rib cartilage and an implant. Each has their own advantages and disadvantages and the results are not always similar. When using septal grafts this supply is limited and given that some of that is used for the tip there is not as much available for the bridge as one would think. Thus using septal cartilage for the bridge will only create 2mms or so of augmentation. (see attached 1st rhinoplasty prediction) More substantial cartilage augmentations require rib grating where the amount of buildup is more substantial because there is more material to use. (see 2nd rhinoplasty prediction) Thirdly the use of an implant (hand carved ePTFE not silicone) works really well in isolated bridge augmentations and produces maximal augmentation results like rib grafts but without the donor site and less operative time to perform.

Knowing how you want to do your augmentation rhinoplasty will allow a proper cost of surgery to be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want my forehead lowering, my chin is too small and my forehead is big and it is asymmetrical.

A: Thank you for your inquiry and sending your pictures. The forehead lowering appears straightforward and the only issue there is how much hairline lowering you think you need and whether it can be achieved. The way to answer that question is for you to draw on yourself the ideal hairline position and take a picture of it so I can determine what is possible. For the chin the debate is not whether you would benefit by increased horizontal projection but how best to address the chin/jawline asymmetry for which there are two options. A sliding genioplasty is the historic approach as it can bring the chin forward as well as slide it over to the midline. While that is good from the centering of the midline chin point, that does not really address the jawline behind it and leaves bony stepoffs along the jawline as well. Ideally a custom chin implant addresses all aesthetic needs more completely but costs more to do so and involves an implant. In short both methods are valid approaches but each has their unique set of disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in getting a custom jaw implant and sliding genioplasty (don’t know if I am a right candidate for genioplasty or chin implant, please see my pics). I want to get a shape like Brad Pitt. I know I won’t look exactly like him after this procedure but I wanted to give you an idea of what kind of shape I’m looking for. Also, in my picture you can clearly see my forehead is gone in a little bit. So please advice me on that, if I should get a implant for that. Lastly, do I need cheekbone implant?

A: Thanks for sending your pictures in this additional email. I have done some imaging for you looking at jawline augmentation alone as well as with infraornital-malar and forehead augmentations from which I can make the following comments:

1) I believe you are correct in that a bony genioplasty with custom jawline implants is best for you because you have a vertically short chin which needs an 8 to 10mm lengthening. This is best done with an opening wedge intraoral bony genioplasty to which the jawline behind is matched with custom implants. When you get into vertical chin lengthening at 8mms and above the soft tissue chin pad will not stretch over an implant. When you drop down the bone, however, the soft tissue chin pad comes with it. That will also help the depth of your labiomental fold as the soft tissue is stretched/lengthened down as well.

2) I added on infraorbital-forehead augmentations in a second set of imaging with the jaw augmentation predictions. As would be expected these help your overall face as they continue the reshaping effect to the next two levels above the jawline. (jaw-cheek-forehead facial architecture) Whether you do one, two for all three levels in a single surgery is a personal choice.

3) Imaging is provided and it is important to understand its role in facial reshaping surgery. These are examples of one degree of change for any facial structure altered, this does not mean it is the only type of change possible. Imaging creates a dialogue to help better determine what degree of facial change a patient is seeking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you would have time to pop a quick email response back to me with some advice and quotes. I have a heavy lower 3rd of my face. I have seen a variety of ways to address this (jaw reduction, buccal fat removal, perioral mound lipo, facelift) and I’m wondering what he would recommend. My goal is to have cheeks that are round and full in the front and a vline, slimmer jaw shape that is not so bottom heavy and long. When I lift the tissue around my jaw towards my cheeks/ears it helps me get more of the look I desire. I will attach some photos! Thank you. 

A: Thank you for your inquiry, sending your pictures and detailing your facial concerns/objectives. Your facial reshaping question is a common one to which I can make the following comments:

1) While pushing/pulling the tissues back along your jawline in front of the ear creates the desired lower facial reshaping change, that does not mean that a lower facelift will end up with the same result in a young person without significant tissue laxity. In other words, the ‘facelift’ maneuver over estimates the effect it can create and sustain. And this should not in a young person be the go to first procedure for lower facial slimming. That doesn’t mean it should never be done but it should be either the procedure of last resort or a complementary procedure to others being done

2) For you the procedures of bony jaw angle reduction (width only), masseter muscle reduction and perioral/lower facial liposuction would be the foundational procedures.

3) You have good cheekbone structure but to enhance that further buccal lipectomies with anterior cheek augmentation using either the buccal fat as pedicled transfers or converted to fat injections or a small malar shell implant would be the approaches to achieve cheeks that are rounder and fuller.

Dr. Barry Eppley

Indianapolis Indiana