Your Questions

Q: Dr. Eppley, Curious about paranasal or paramaxillary implants. I have poor midface projection and my upper lip doesn’t project as much as I want it to. Would love to discuss this and a chin implant.

A: Thank you for the inquiry and sending your pictures. Based on your pictures you are referring to a paranasal-maxillary augmentation. I don’t think you are referring to a premaxillary augmentation as, besides not being able to project your upper lip any further  (the upper teeth are primarily responsible for lip projection), it will also open up your nasolabial angle and push out the base of your nose across the anterior nasal spine, which with a long upper lip I wouldn’t think you would want that type of midface change.

As for your chin I would predict that you need increased anterior projection but with a decreased vertical height and no increase in width. That type of chin change may be better suited for a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my chin burred down and jaw implants put in ten years ago. Worst decision of my life as my face was asymmetrical and the implants accentuated my asymmetry.

Biggest issue is my Chin Ptosis. I ended up with lip incompetence , severe lower teeth show, flat mentolabial fold and droopy chin.

I am in a desperate situation and I feel aging is making things worse. Been very self conscious about my chin for the past 10 years.

Was currently considering going to South Korea to see a maxillofacial who can help me with my asymmetry and Chin Ptosis until I stumbled upon your name several times . I felt it was a sign to contact you first.

Please take a look at my pics.

A: Thank you for sending your pictures and detailing your surgical history. Any time the chin is burred down for reduction, particularly if done intraorally, chin ptosis will always result. It is not a question of whether chin ptosis will occur but how severe it will be. 

Correction of chin ptosis in the face of lower lip incompetence must resuspend the soft tissue chin pad upward. But this will not be successful unless there is a ‘ledge’ to help hold it up. Whether that is from the placement of an implant or from moving the chin bone forward, the soft tissue chin pad needs support.

While chin ptosis correction can also be done by a submental tuck from below that risk making the lower lip incompetence worse. That approach should only be used when good lower lip position and competence exists.

Given what you have been through and to be more thoughtful in any further efforts, the next step is to get a 3D CT scan of your lower jaw/face. It is time to see what the actual bony anatomy looks like as well as any implants therein.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have large cheek implants in the front of my face. It gave me projection to my mid face which addressed my 1st concern buh didn’t fulfill my 2nd concern to have a wider more angular face. Can i have a 2nd surgery and get extra large implants to put on the sides of my cheek ( and still keep my large midface implants)?

A: That is probably not the best approach to try and place two cheek implants on top of each other. It would be very difficult to get two separate cheek implants close to each other and have then be stable in position. You are asking standard cheek implants to really do what they are not designed to do. You would be far better to have one unified custom cheek implant design which can more effective address your needs and have much lower risk of malposition and asymmetry than four standard cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a square jaw and wide cheekbones which give me an overall square face look.I am right now seeing who’s the best doc for the job. So far all the maxillofacial that can help me seem to be in South Korea, which I have no problem of going to but if I could find something in the US I would prefer that. Here I will attach a photo. Without me telling you what I want, what would you recommend. I am open to everything as long as the risks of complications are kept minimal.

A: Thank you for your inquiry. In the treatment of your wide cheekbones and prominent jawline, you are correct in that bony reduction of both cheeks and jawline is needed. The cheekbones are straightforward as there is only one way to reduce them…anterior and posterior cheekbone reduction osteotomies. The jaw angles/jawline is different in that there are two procedures, 1) lateral corticotomies (thinning) with mild blunting of the actual jaw angles  or 2) jawline angle/jawline amputation for a more radical reduction which eliminates the jaw angle completely. Without seeing a 3D CT scan of your face bones as well as a side and oblique pictures I can not say which may be better in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, First of all it is a great respect and i have to say I admire your facial reshaping surgery work. If one were to do those procedures, what would be the correct order and spacing? 

Rhinoplasty 

Otoplasty 

BSSO and GENIO 

Wrap around jaw implant 

Cheek implant 

Brow ridge and fore head implant 

Eyebrow transplant 

Lip lift and mouth widening? 

And out of those if I were to do the followingwhat will be the cost overall? 

Custom Forhead implant 

Custom Browridge implant 

Custom cheek implant 

Custom wrap around implant 

Lip lift 

Mouth widening 

Rhinoplasty 

Otoplasty

A: Thank you for your inquiry about facial reshaping surgery. Much like building a house you start first with the foundation…in your case the BSSO/genioplasty. Thereafter you build on that foundation six months later with any facial implant augmentations and rhinoplasty. Then the third and final stage would be any lip procedures since all of the other procedures cause too much swelling to make the sensitive lip area amenable to good scarring.

Since it is not yet clear what actual procedures would be done, for now I will have my assistant Camille quote the facial implants and rhinoplasty as done during the proposed stage 2 of the facial reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the head/ temple and jaw widening procedure. I know you have designed some jaw angle and temple implants for mass market use. As I would most likely not want to have another CT scan done do to multiple scans within the past few years from an unrelated accident. My timeline for surgery would most likely be mid next year. My questions are as follows : 

As I do have hollowed temples, would I need both front and side temporal implants or would the sides cover correctly this ? 

What would a ballpark figure be for said surgery with custom vs implantech implants? 

I know this may be a lot to ask but numbers do not have to be precise 

Thanks and kind regards

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

1) Standard temporal implants are for hollowing that exist by the side of the eye in the non-hair bearing area. How that applies to your situation its unknown since I don’t now what you look like.

2) The term ‘jaw widening;’ can mean either just the jaw angle areas only or could be the whole jawline. Like #1 without knowing what you mean exactly I can say whether those goals are achievable with standard or only custom designs.

While my assistant is happy to provide costs of surgery, it is not clear whether standard or custom implants are best in your case. I need more information (pictures and your exact goals) to provide a qualified answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from moderate plagiocephaly.  My biggest concern is the asymmetry of my face as one side seems to bulge out. In my case the flatness of the back isn’t as severe as the front. Is it possible to have reshaping of the front of my head and brow and maybe to contour my cheeks so it doesn’t looks too severe? My eye is also bulging a little bit out but i don’t think it’s fixable.

A: Thank you for your inquiry and detailing your facial asymmetry concerns. The frontal portion of plagiocephaly can be treated as successfully as the posterior portion, it just involves some more complex topographic assessment and treatment than the more uniform back of the skull contour. Please send me some pictures of your face for my assessment and recommendations. A 3D CT scan is always needed in the assessment of facial asymmetries but pictures would be a good start to the assessment process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question about my custom infraorbital-malar implant design. I notice that the back end of the zygomatic arch comes to a blunt end with 2mm thickness Why is it this way as opposed to tapering to a feathered edge? 

A:To refresh your memory as to this very topic we discussed during the custom infraorbital-malar implant design process, the tail end of the zygomatic arch is not usually tapered to a feather edge for two reasons:

1) A fine feathered edge is very prone to flipping up or rolled over during insertion which is never seen during placement…only to appear later when the swelling goes down as a prominent bump. I have learned that lesson more than once.

2) If it is tapered and the design fades from front to back there will be no visual evidence of an arch component at all.

These are the two reasons I don’t taper the ends. Most of the back ends of the arch component are often much thicker in the 3 to 4mm range as a blunt end. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In regards to forehead horns I have three questions: 

1) is it almost always an extra amount of bone, rather than the shaping of the skull? (meaning the skull is shaped rather normally underneath and the excess can be burred off?) 

2) if a “safe” amount is taken off, will integrity be sacrificed at all? If I were to play a contact sport or something after reduction, would skull damage be any more likely? 

3) is there another name for these? Is it just pretty rare? You’re basically the only surgeon who comes up when I try to look in to this.

A: In answer to your forehead horn reduction questions:

1) The exact origin of forehead horns is nor precisely known. But they are a prominence of the upper forehead that can be burred down if that makes for an aesthetic improvement of the shape of the forehead. In some patients that have an overall greater retroclination to the forehead it may be better to build up the bone around the horns as a method for their ‘elimination’.

2) The amount of bone reduced in forehead horn reduction does not compromise the integrity of the frontal bone.

3) The term ‘forehead horns’ is a well known term for these upper forehead prominences that has been in use long before I ever treated them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I was just wondering, If I got 5cm custom hip implants in really soft implants would they have a risk of folding in the healing process? Because I was told that the normal 5cm implants may cause erosion of the underlying tissues, meaning I would have to have “really soft” 5cm ones, but they may fold whilst healing. Is this same risk with your implants? I just want a second opinion because I’m either going to get my hips done with you or the other place I’ve contacted 🙂 thank you so much. 

A: At 5 cm hip implant thickness, even the ultrasoft silicone is going to feel very firm/hard. The thicker an ultra soft solid hip implant is, the more firm it will feel. This is just a function of material thickness. While at 1 cm it will feel very squishy, at 5 cms it will be almost as firm as a brick. Because of this issue and others, I would never place a hip implant that was more than 2.5 or 3 cms thick at most. This is just asking for a complication of some type.  Hip implants are unique because they are not in or under muscle but on top of its fascia. This makes for higher rates of potential complications. By a lot of painful experiences i can only pass along this piece of wisdom….’it is far better to have an uncomplicated result that may be only 50% of your aesthetic goal than it is to have achieved 100% of your aesthetic goal with complications’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Is there a difference between submental liposuction and submental lipectomy? Do you perform both procedures if this is the case?

A:Technically there is a difference between submental liposuction and submental lipectomy. Submental liposuction, as the name implies, removes fat between the skin and the platysmal muscle by vacuum extraction using a cannula. (like any traditional lipouction only using a smaller cannula) Submental lipectomy is the direct excision of central fat beneath the platysmal muscle. in the midline The combination of submental lipectomy and submental liposuction is always part of the procedure known as a submentoplasty. A submentoplasty is a more aggressive form of neck contouring that also include platysma muscle tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Regarding limitations in the size of facial implants, such as chin implants, would the skin not eventually stretch, gradually, to accomodate the implant? That is to say, have you ever had someone get an implant, wait a year, get a larger implant, or is this irrational? Would the tissues simply become too tight regardless of how long was waited? I know, for example, that as people get fat, their skin extends generally regardless of how fat they get. Is there not the same potential for cosmetic implants? Is there any experimental work being done in this area?

A:It is very common that patients unintentionally undergo a first stage tissue expansion procedure (placement of an initial implant) for a second larger facial implant later. They get one implant size today and then may decide later they want it bigger…which is not a problem to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing this email in regards to the query regarding the custom jaw implants. I had a V-line surgery done around 3 years ago in Korea and since then I have almost lost my jawline definition. I am looking to reverse this surgery dr. Probably around in coming 1-2 months or as soon as I get a leave from work.Actually my question is not regarding the custom jawline implant but regarding the possible implications of it on my future surgery. Actually I am scheduled to get a Lefort 1/ Upper jaw surgery. Its ONLY an upper jaw surgery but not a double jaw surgery. Currently I am undergoing orthodontics and it is scheduled for Summer, 2020. My maxillofacial surgeon is very confident that it is only going to be upper jaw surgery with some setback and Clockwise rotation with some posterior impaction. He said that he won’t touch my lower jaw at all. So my questions are:

1.Is it possible that I can get a custom jaw implant to reverse my V-line surgery  and for jawline augmentation in upcoming August/September 2019 and then still in 2020 can go upper jaw surgery only for my maxilla without any compromising effects on my jaw implant. 

2.Will the custom jaw implant create any hindrance if my maxilla is impacted/rotated or setback or if it has to be removed during my maxilla surgery.

3.Can I get a custom jaw implant now on my mandible but still in future can undergo ONLY upper jaw surgery without any problem.

Thank you so very much for your time Dr. I am really looking forward to get my custom jaw implant with you. My basis of this query is just that as I can get leave now from work and I would like to get my custom jaw implant with you now as I really dislike my un-defined jawline. Looking forward to hear from you soon.

A:Thank you for your inquiry and detailing your issues and upcoming maxillary surgery in 2020. I think all of your three questions revolve around the same issue…can a jawline implant interfere with any aspect of a subsequent LeFort 1 osteotomy? And the answer to that would be no. As long as you know that you are not going to need bimaxillary orthognathic surgery, then placing a custom jawline implant will be just fine.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is a direct temple lift the same or different than an endoscopic browlift? Or I assume the direct temple lift pulls the tail vertically while the endoscopic browlift pulls the whole brow up to the hairline.

A: There are differences between a direct temple lift and an endoscopic browlift. An endoscopic browlift uses 4 scalp incisions  (2 parasagittal and 2 temporal) to create a total brow lifting effect. Conversely a direct temple lift uses an incision either at the tail of the eyebrow hairline, at the edge of the temporal hairline or back in the temporal hairline to create a tail of the brow lift. Most commonly the incision is placed at the edge of the superior temporal hairline which lifts the tail of the brow in a 45 to 60 degree angulation upward. 

The combination of a lateral cantoplasty and a direct temple lift is the most powerful technique for creating an upward sweep or angulation to the outer eye area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, this is about mouth widening surgery, I saw online about a question about how mouth widening surgery can improve the length of the mouth and Dr. Eppley answered about 5mm on both sides of mouth, Is that right? I don’t see how wider the mouth can get without cutting too far into the muscle which can be dangerous.

A: All mouth widening surgery involves removing a wedge of orbicularis oris muscle as that this is a necessity to help prevent relapse. There is nothing dangerous about such muscle manipulation/removal. This is a small wedge of the lateral aspect of the muscle which has no functional significance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eyelid surgery to correct negative canthal tilt. I know lateral canthopexy can be done to raise the lateral canthus but i also need the medial canthus to be lowered in both eyes. I talked to one doctor who told me it is impossible to do. I started researching this and found many articles on the topic that have been published throughout the years. All of them describe methods and techniques for reattaching the medial canthal tendon. When i sent one of those articles to the surgeon he told me those techniques do work but they’re only for “medical problems”. I even saw a video of of the procedure being done. I e-mailed another surgeon asking him if it is possible to do and i suggested cutting the bone to which the tendon is attached and moving it down then fixing it in that position. I asked him if that would work and he said that it would and that he’s done things like that before. I just don’t see any reason why this can be done for people who have severe skull fractures/shattered orbitals but not people who are perfectly normal? Is it possible to do or is it impossible? I’m confused and just looking for a real explanation.

A: Medial canthoplasty is a far more challenging procedure than lateral canthoplasty due to the more limited access of the inner eye and the very thin bones to which the tendon is attached. It is also a procedure that is far less successful as a result. While attempting to do it for reconstructive purposes has merit, manipulation of the medial canthal tendon for aesthetic purposes must be considered far more carefully. I would doubt that moving the inner corner of the eye down will be successful if attempted by trying to move the medial canthal tendon downward. The bones of the medial orbital wall are very thin due to the sinus cavity that lies on the other side. This makes secure fixation very difficult. If the goal is to move the inner corner of the eye downward boy a few millimeters it would far more sense to do so by skin manipulation such as a small z-plasty. It would be more effective and incur none of the risks of destabilizing the medial canthal tendon attachments.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in jawline custom implants but what material does the you use? 

A: A custom jawline implant can be made by a variety or materials from solid silicone, Medpor, PEEK or titanium. I am not married to any of them, ultimately that is the patient’s choice. However they are not all equal, meaning there are major differences in cost, how they would be placed (one piece or sectioned into multiple pieces) as well as the size of the incisions to place them. The reason solid silicone is chosen by most patients is its lower cost, ability be placed as a single unified implant and the smaller incisions used to place it. But I have had lots of patients who have chosen other more expensive materials and had equally satisfactory results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for the detailed reply and the options therein. When considering the submentoplasty procedure for neck sagging problem, my questions/concerns are as follows:

Putting aside (for the mpment) the expense of the work needed, there is, for me, the more difficult or challenging elements of having the work done without it being readily identifiable as someone who’s ‘had some work done’.

Can the procedure described be done in stages so as to minimize its obviousness? In the closing paragraph of your last email it appears that you are alluding to a sequence of steps, could those steps be the thresholds for a series of successive procedures or are they too intrinsically woven to be approached separately ?

It’s important to me that my friends and family think I’ve just had a vacation, fallen in love, or gotten laid properly (or all three) when they first see me after the operation.

Additionally, I’d like to know what the pain management path is; would I be put out for the operation,  is the time envelope for the work an hour or two, or significantly more? In terms of pain management history,  I have had some oral surgery and dental implants over the course of a few decades and have always insisted on anesthesia – not the local variety, but rather being put out by an attendant Anesthesiologist.

Logistical speaking, do I need to be swaddled in bandages fo a day, or three, or a week or more ? Travel considerations ?Time of year ?

A: In answer to your submentoplasty questions:

1) The concept of someone wanting to have facial work down and not looking like work has been done is not an issue you should be concerned with given the type of procedure you are considering. By definition a submentoplasty procedure simply can not look overdone. Its real issue is whether it can fully address your neck concerns. So the potential issue is really the opposite of what you think….not looking overdone but can it do enough to satisfactorily improve the problem. If you remember my discussion of your options, the ideal treatment for your neck concerns is a lower facelift. You just may not be ready to undergo that effort at this time.

2) The submentoplasty includes all three components that I discussed which have to be done at the same time. There is no benefit to staging them from a result or recovery standpoint. 

3) Changes in the neck are not really noticeable to other people as a specific identifiable change as people are not that perceptive. They may only ‘notice’ as some type of overlay beneficial change.

4) This is not an operation that is associated with much pain as most facial/neck procedures have low levels of discomfort.

5) Such procedures are done under general anesthesia.

6) There is a chin/neck strap applied for one day after surgery. Thereafter its use is optional.

7) You could return home 1 to 2 days after surgery.

8) The best time to is such surgery is when it suits your schedule the best. Time of year and weather make no difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My paranasal-premaxillary area is very recessed. I was wondering If is it possible to do paranasal-premaxillary augmentation with fat grafting. I know that peri-pyriform implants exist, but I want to know If fat grafting can achieve 4mm or more augmentation. Thank you Dr.

 A:Thank you for your inquiry. Can fat grafting be done to the midface and can an initial 4mm paranasal-premaxillary augmentation be achieved….the answer would be yes. The question is not whether fat grafting can be done to the midface but whether it would be successful. (i.e., survive) My experience and the observation from patients who had it done by other doctors is that the survival rates are low. There is also the issue that, even if it survives with some reasonable volume, the look is often more of a bloated/full one and not that of a skeletal augmentation effect which is the source of the problem. Once fat grafts are in there should the look be undesired there is no good way to remove the fat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have crater chest deformity. I had not long ago had gynecomastia reduction surgery and it’s gone horribly wrong. My nipples are caved in and they are partially black. I am devastated. What do I do now?

A: Thank you for the clarifications and sending your pictures. What you have is an over resection of tissue through an open gynecomastia reduction approach that has left both a crater deformity as well as partial nipple-areolar necrosis. While I don’t know exactly how long ago the surgery was I would suspect on the appearance of the nipple-areolar complexes that it as just a few weeks at longest. 

Your options at this point are the following:

1) Let the extent of the crater deformity and nipple-areolar necrosis declare itself (the extent iof the contour deformity and how much the nipple-areolar complex will survive) over the next few months and then treat secondarily with fat grafting and nipple-areolar scar revision, or

2) Undergo immediate injectable fat grafting to help restore the contour and possibly limit the extent of the nipple-areolar tissue loss. (what is black is likely full-thickness tissue loss) This still may require some revision later but by adding healthy tissue back in with some stem cells it will expedite the healing process as well as provide some early contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting youfAfter reading your answer on Real Self. I am very much worried as I had a terrible otoplasty that left my ears over pinned (3 months ago), it is a true nightmare as I asked the doctor not to do it!!! I am just curious about any possibility to make my ears stick out again. You wrote that the ears can stick out again trough an incisión of the scar tissue that is holding the ears folded. Is this enough or do we have to mold the cartílage again?What could you recommend me to do? Doctor used Stenstrom technique with one absorbable stitch per ear. Thank you.

A: It is unlikely that just release of the sutures will make the ear come back out as the memory of the cartilage is now lost at three months after surgery. That only works in the first few weeks after surgery. It now requires a tissue bank cartilage graft to hold the ear back out once it is released. That is the fundamental principle of a reverse otoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had eyelid surgery before. I had festoons so to get rid of them the Dr. pulled my lower eyelids and now they bow. I look Asian now. I would like to put in an orbital rim implant and small lower cheek implant. I also have one eye that looks closed and i am not sure if because pulling on lower is forcing upper down. My questions are:

1) Can we add a orbital implant under eyes plus lower cheek bone implant to add fullness because I look caved in?

2) Can you make me look less Chinese and have an eye shape like I had before?

3) Can you work on upper lid so it doesn’t look like my eye is closing and maybe work on one or both upper lids? I have big scars and hopefully can reduce scars??? After surgeries and healing occurs can have scar reduction surgery???

A: Thank you for your inquiry and describing your eyelid concerns. By your description you had an aggressive lower eyelid procedure in an effort to ‘lift out’ the festoons. (which is very prone to lower eyelid ectropion problems) The bowing down is the rounding of the lower eyelids due to loss of vertical height. The upper eyelid issue is a bit unclear to me. But I will need to see pictures of your eye area to provide a more qualified opinion. Until then I can answer your questions as follows:

1) An infraorbital rim-malar combined implant can treat the caved in look which is the result of inadequate volume.

2) To get your eyes back to normal and less deformed, it will require a combination of #1 and lower eyelid reconstruction with spacer grafts for the lower lids and lateral canthopexy.

3) I am as yet unclear about your upper eyelids so I shall wait to comment until I have seen pictures of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year-old make and I am interested in reducing the sagging underneath my chin (upper neck area – below the jaw)

A: Thank you for sending your pictures. You have the classic beginning of a  neck sag with a central band of tissue running down the center of the neck between the chin and close to the sternal notch. Of all the tissues in the neck that can sag, this type of neck band is largely skin. This is a what I call a ‘tweener’ neck contouring problem. Meaning if was more severe you would absolutely need a lower facelift/necklift and if it was less severe perhaps liposuction alone may be adequate.

While it is important to point out that a lower facelift/necklift is the definitive treatment for your neck problem, I will make the assumption that you may not be committed to going quite that ‘far’ just yet. A direct necklift would also be tremendously effective but you are too young to do well with a central vertical neck scar in place of the central neck band.

Thus this leaves the submentoplasty procedure as the most viable option. One trough a small incision under the chin it is a three level central neck contouring procedure consisting of a combined liposuction above the platysma muscle, direct removal of subplatysmal fat and plastyma muscle plication or corseting…all done with the neck reshaping intent of improving the cervicomental angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a very tiny 28 year old who is constantly mistaken for being 15. I have a 32AA cup size, and my torso goes straight up and down with no curves. My hips do not curve out more than my waist. In addition, I am also 5ft tall so my ribs are only about 3/4 of an inch above my iliac crest. Because of this, I believe I have no inward curve of my waist. Rather than implanting silicone to fill my bust, I feel I would be more confident with a rib removal to enhance a curve and make my waist skinnier than my hips. I do not believe I need a tummy tuck. I have a tiny bit of fat on my rectus abdominus, external obliques, and lower back combined. But my waist circumference is 29 and my hips are 33. I only weigh 103 lbs while I am 5ft0in tall so I do not have a lot of fat. My stomach does protrude past my flat chest into a bit of what looks like bloating, but I always have this shape. I have visible abdominal muscles below my tiny bit of fat, which is why I don’t think I would need a tummy tuck.

Two questions: 

1) Do you think rib removal without a tummy tuck would give me more of a womanly shape (smaller waist to hip ratio)? Where would the scars be and how big without a tummy tuck?

2) Do you think I am chronically bloated or store more fat internally (greater omentum) rather than on top of my abs? Like I said I am only 103 lbs, 5ft. 29 inch waist and 33inch hips. but my stomach protrudes almost looking like I am 3 months pregnant perhaps. I have also been told by my parents that this “protruded stomach body shape” runs in the family and is thought to be Lordosis. Could this really be the case?

A: Thank you for your inquiry and providing the details of your body shape and objectives to which I can make the following comments:

1) Rib removal for horizontal waistline reduction is done through small (4.5 cms) oblique back incisions and removes ribs #11 and 12 and usually #10 as well. This is never performed through a tummy tuck as these ribs are not reachable from that anterior approach.

2) The type of rib removals done through a tummy tuck approach are the anterior subcostal rib cage margins of ribs #7, 8 and 9 and is done for subcostal rib protrusions not horizontal waistline reduction.

3) Very thin and petite women are one of the major patient groups that seek out rib removal surgery for the exact reasons you have described….to provide some inward curve to an otherwise straight torso.

4) Being thin and virtually having no breast tissue, even low weight females can have a pseudo abdominal pooch. It would be exacerbated by a lordotic condition for sure. Whether that applies to you I can say since I do not know what your body exactly looks like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face has a lot of asymmetry to it. One eyebrow is significantly higher than the other. My chin points more in one direction. It almost appears as though one part of my face stopped growing with the other half. I had braces a while back, and I remember having a pretty dramatic shift in my teeth (bracket came out of holder). My TMJ worsened, and I believe it all goes hand in hand. I was told this couldn’t be fixed because it was a vertical bony orbit asymmetry. 

A: Thank you for your inquiry and sending your pictures. You have a right-sided facial hypoplasia which is most manifest at the north (eye) and south (chin) ends. The most significant component of your facial asymmetry is your vertical orbital dystopia (VOD) and the surrounding changes that come with it from a lower orbital box. (lower brow bone and eyebrows, lower upper eyelid, lower globe position, lower orbital rim and smaller cheek) 

It is not an accurate statement that it ‘can’t be fixed’. While perfect eye symmetry may not be achievable, significant improvements can usually be obtained. The first step in the diagnosis and treatment planning process is a 3D CT scan which will clearly show the bony differences and what can be done to improve them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, During our initial video chat I had mentioned that the second lip lift had also caused further descent of my nasal sill resulting in increased nostril show from the front. I consulted some other surgeons in LA about it around the same time, and like you, they all said that nothing could be done to raise the sill back up but I was told by two of them about another way to potentially address the problem. From looking at my side profile (attached for you to see), they both said my nasal tip seems to be rotated upward quite a lot and that I could afford to rotate the tip down with a septal extension graft, and that could correct or at least significantly improve the problem.

I’ve seen some before and afters and it definitely seems worthwhile. I was interested to know what you thought as well.

A: While it is true that you can’t raise the nasal sill back up, it may be able to be partially camouflaged by tip rotation. Doing some computer imaging from the side profile it should be able to be demonstrated whether that is a valid aesthetic effect/concept. On paper it would seem to be but ‘seeing’ is believing from the patfient’s perspective.

When it comes to downward nasal tip rotation there are the two ways to do so. An internal septal extension graft is one option which provides a push of he tip cartilages downward from behind. The other approach is infralobular onlay grafting (using septum) to build out he tip cartilages and push the skin down. Having used both I have found either approach can work. The choice would depend on how much tip rotation is needed to create the desired effect. I will have to do some computer imaging and would need a side view picture of your nose to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in doing a brow lift. However I noticed a lot of surgeons in specific countries are proposing that an endoscopic brow lift with an endotine ribbon provides a more fixated and long-lasting result compared to traditional endoscopic brow-lifts.

I also had never knew Endotines supplements other lifts such as: Face lifts, Neck-Lifts, Forehead, and etc. 

What is your opinion on this? I am interested to get a few surgeries by you. I was curious on your forehead lifts.

A: While some form of fixation is useful in all endoscopic brow lifts, there is no clinical evidence to support the contention that the result is better short or long-term with use of either an endotine platform or ribbon. There are many different forms of endoscopic browlift fixation (e.g., screws, bone tunnels) and the only thing that is clear is that one of them is needed. I have used resorbable/metal endoscopic screws and bone tunnels for years and they work very well. The key with whatever form of fixation that is used is how easily it is inserted through a small endoscopic incision and what aesthetic risks come from their use.

But being a male seeking a browlift, the form of fixation used is the least important consideration in your surgery. The most important is whether your hairline location and density can support a superior scalp approach or whether an inferior transpalpebral (through the upper eyelid) approach is needed. If done from below then the only form of fixation that can be used is the placement of an endotine platform.

I would need to see pictures of your forehead to make that determination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Are hollow cheeks an asset or liability? I’ve been considering filling them, but am hesitant. Wish I could attach some photos. 

Models have them. So do gaunt faces. 

Why is it some can look so young with hollow cheeks while others so old? 

Is it simply the degree of hollowing? Or is there something more, like the distribution of fat— so that someone could be “hollow in a good way” or “hollow in a gaunt way”. 

Is it a male vs. female thing, with males looking chiseled and females gaunt? 

Yet another possibility I could think of is that hollow cheeks complement some bone structures but detract from others. 

The photos attached are of my cheeks. I’ve been considering filling them to restore youthfulness. Advised I’ve received has ranged from “recommended, will turn the clock back years” to “are you crazy, you know how many people want hollowness like that but can’t get it”. Please advise!

A: Since I have no idea what you look like or your idea of facial aesthetics I can only make the following comments:

1) There is a difference between youthful and isolated hollow cheeks and an age-related overall facial lipoatrophy in which hollow cheeks occur. The youthful one can be aesthetically appealing (hollow on a good way), the aging one never is. (hollow in a gaunt way)

2) What level of cheek and jaw bony prominence that exists around hollow cheeks has a major influence on the perception of hollow cheek aesthetics.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel that addressing the visible septum in left nostril and the rightward curve in the lower third of my nose will go a long way in improving my facial symmetry.  Based on what happens when I push the septum into a central alignment, I think that the septoplasty will help to lower the right nostril which is being pushed up and to the right by the deviated septum.

While my understanding of the basics of a septoplasty are pretty clear, I have a few questions. First, do you typically perform these as an open or closed procedure? Second, do you anticipate that the straightening of the septum could result in a shortening of the nose? I am currently bothered by the tip of my nose sometimes rotating up and showing more nostril. I have read that an upward tip rotation is sometimes a complication of septoplasty and was wondering if there are ways to help prevent this.  

Lastly, is there a way to very slightly lower the effective alar rim height or alar arch to reduce nostril show through the septoplasty (in other words, besides a separate complicated grafting procedure)? Is there a way to increase the length of the septum to slightly rotate the tip forward/down?  Below is an example of how much improvement even a mm or two of alar arch reduction provides.

A: In news to your septoplasty questions:

1) While a septoplasty will reduce the appearance of it into the left nostril, it would be a procedure that I would expect to lower the right nostril rim. As I have never seen an isolated septoplasty make that happen nor can I envision the anatomic reasons why it would.

2) All isolated septoplasty procedures are performed closed.

3) Straightening the septum would not make a nose appear shorter per se. Expecting that outcome is the same as that of it being capable of lowering a high alar rim.

4) I am not aware of ever seeing an isolated septoplasty create nasal tip rotation nor would there be a anatomic explanation for that effect. When septal shortenng is performed at the same time as other tip procedures with the specific intent of tip rotation it has a useful role at that time.

5) Lowering an alar rim requires placement of a graft to do so since this really represents a tissue ‘defect’. If done using a closed approach a chondrocutaneous ear graft is needed. If part of an open rhinoplasty a cartilage alar rim graft Is used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a male interested in having several procedures, preferably done in one session if possible.

I am wondering if it would be possible to have the hairline lowering and custom brow ridge implants be done through the same incision along the hairline to minimize scarring?

With the infraorbital implants I am looking to correct my negative orbital vector, but am also hoping that the saddle will provide support decreasing the vertical measurment of my eyes slightly. Would this be possible?

One concern is the fact that I previously had lower eyelid retraction surgery (midface lift) through the inside of the lower eyelids. Could the placing midface implants through the same incision site wreck my previous eye work?

Thank you.

A: Thank you for your inquiry and asking all very good questions to which I can provide the following answers:

1) A hairline or pretrichial provide excellent access for the placement of a brow bone implant.

2) An infraorbital implant that increases its vertical height (which by definition means it saddles the rim) can create some lower lid leveling/elevation as there is a relationship between lid-infraorbital rim levels. The key is that it just be a vertical infraorbital rim implant style.

3) While I don’t know what type of midface lift you had and where the vectors of support are, the elevation along the infraorbital rim does not extend into the cheek area. So I don’t envision, based on what I know now, that it would disrupt a prior midface lift.

Dr. Barry Eppley 

Indianapolis,Indiana