Your Questions

Q: Dr. Eppley, I am interested in injectable lipoma removal. I have a small forehead lipoma about the size of a quarter near my hairline that I want to inject with Lipodissolve to get rid of it. Will this work and will int injection do it?

A: For a forehead lipoma that lies near the hairline the far better and more efficient solution would be to remove it through a hairline incision. Lipodissolve (now reinvented and marketed as Kybella) solutions are not FDA approved for the face and it would take 3 to 4 injections sessions spaced  6 to 8 weeks apart to get it as flat as possible….provided it will respond to the injection. In a thirty minute surgery done under local anesthesia an excision will remove the lipoma intact on an assured permanent basis. 

With such a small lipoma that lies right up against the hairline the small incision needed to remove it would leave an imperceptible scar in its wake. While an injectable approach sounds like it would be quicker and easier to do, the reality is that it is currently inferior to surgical excision for the reasons so discussed. It would also cause much more swelling each time it is injected that its surgical removal would create.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in short face surgery. I have a very short lower face. I had been on braces for the past 2 years and now on retainers. While the alignment of my teeth has improved and it’s almost a normal occlusion, I’m still not happy about my aesthetic facial results. Here are my main concerns:

My lips are actually over lapping each other and as you can see the upper lip actually rolls inside the upper teeth giving it a weird shape. I feel this is due to the deep seated maxilla and teeth which supports my upper lips inadequately.  I do not show any teeth when I smile. I have a non-existent jawline and a slight double chin despite being relatively lean.  My chin appears receding and gives me a chubby look. 

Here are a list of my expectations : A proper support to my upper lips by my upper teeth and proper visibility of my upper teeth when I smile naturally and even when I talk . A balanced chin for my face and a visible jawline and to remove the bloated look on my face and give it some structure 

Here are my questions: 

1. Can you please explain the cause of such aesthetic issues for me. 

2. What would be the best course of treatment in your opinion?

3. If you are gonna suggest double jaw surgery with vertical and horizontal advancement and genioplasty, can the pre braces phase be done away with , now that there is proper alignment between my teeth. 

4. I get pain in the jaws when I chew on something hard. Would it also benefit from the surgery ?

5. Would my already prominent nose get wider  if I opt for a maxillary advancement ?

6. Are there chances of relapse of the maxilla after surgery ?

A: In answer to your short face surgery questions:

1) What you need is vertical facial lengthening. The key to deciding which approach to do comes down to tooth show.

2) If tooth show is a very important aesthetic element then only a bimaxillary orthognathic procedure will accomplish that by dropping down the maxilla 4 to 5mms as well as bringing it forward a bit. The mandible comes with it of course which pulls down the lower face as well. Other soft issue procedures around it would be beneficial (buccal lipectomes, neck liposuction) but the vertical maxillo-mandibular lengthening is the key. (probably a lengthening bony genioplasty would also be done with it of another 5mms) 

This approach increases tooth show and pulls the face longer which will also help make it thinner.

Dropping the maxilla down requires an interpositional bone graft with plate and screw fixation. This is the best way to prevent relapse.

Whether such an orthognathic procedure will improve your jaw pain can not be predicted.

To avoid increased nasal widening from a maxillary osteotomy procedure, alar base cinching is needed during the closure.

If one has a good and stable occlusion, then further orthodontic work is not needed for this surgery as the same bite is maintained. Like bimaxillary osteotomies for sleep apnea (large horizontal movements) this is not a bite-changing surgery.

3) If tooth show is not a primary aesthetic goal, then a 12 mm intraoral vertical lengthening genioplasty or a custom vertical lengthening total jawline implant can be done which will vertically lengthen the face effectively. This will need to be combined with maximal facial defatting procedures as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did breast implant replacement and capsular contracture surgery over one year ago. I am feeling lumps and some hardness in the same breast. Is it possible the capsulation is returning? Is there a treatment or something I can do to stop it from continuing?

A: Capsular contracture is a difficult problem which is not well understood nor are there are procedures that can alway produce a 100% cure of it. Usually once a capsular contracture is released any return of it typically takes place 3 to 6 months after surgery. But it is possible that it could return any time even decades later…although this is not typical.

There are no known medications or other non-surgical treatments that have proven to provide a definitive solution for capsular contracture….surgery is the only proven method to treat and release it. Massage and other external manipulations (e.g., deep ultrasound) can be helpful but have to be done regularly and have only moderate improvements in breast softening.

Once a breast had had capsular contracture it rarely will ever feel quite as soft as the breast that has never had it. As long as it is not painful, has not distorted the breast and does not appear to be progressing then doing nothing for now would be the best course of action.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry surgery. Here is the list I came up with of the asymmetric facial features that bother me the most.. It is in order of which corrections I believe will minimize the asymmetry:

• Cheek

• Jawline/chin

• Lip

• Nostril

• Eyelid

I would like to know your opinion.

A: From a surgical perspective I look at facial asymmetry issues as what structures can be either changed the most successfully (which ones would have the biggest impact on improving facial symmetry) and/or the most straightforward. (which has the least risk to do and is most time and cost efficient but their impact by themselves is limited) Successful and straightforward surgeries are usually not the same.

As that relates to your list:

biggest impact = cheek and chin/jawline

straightforward = eyelid, nostril, lip

The point being is that one usually wouldn’t just do the most straightforward procedures by themselves, that would be reserved for the most impactful. But the overall best effect is going to come from a combination of them in a more comprehensive approach.

The priority list is important as cost considerations may only one to do the top two or three and I want them to be the most effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As a surgeon with experience in Asian cheekbone reduction/narrowing surgery, I hope you can advise me on the best path.

It’s been around 6 months since my surgery. I have thick, acne-prone skin and I believe this combined with the surgical dissection has resulted in some slight cheek sagging. From a bony point of view, I am pleased with the results but I am now consulting to fix the soft tissue aesthetics – by that, the mild sagging. 

I consulted with a highly experienced craniofacial plastic surgeon in my city. He advised me that this type of sagging is nothing he hasn’t seen before with his experience in cheekbone repair and cheek implant removals. His take on my situation was that fillers would be extremely temporary at best and that fat grafting or cheekbone implants would be unideal in my situation with my reason for having the surgery in the first place and my thick, chubby tissues.

The surgeon told me that since gravity was the problem, pulling the tissues back upwards was the solution – He pointed me in the direction of a midface lift (not endoscopic, using sutures) via incisions in the temple and reusing my cheekbone intraoral incisions. 

The procedure does sound like it will address the real issues, but I am very worried as I am only 25 years old. I am very much aware that facelifting in a young individual can lead to disastrous results and I am worried this may lead to a look that is “done” or “windswept.”

I am especially worried about the risks of nerve damage with a subperiosteal midface lift from the temple and mouth. I have read online about another individual’s experience of synkinesis after a midface lift. 

I want to put my faith in my surgeon but of course, I understand that there is no 100% of no complications. As a highly regarded and experience craniofacial plastic surgeon, what do you think of this surgical plan? Is it prone to a lot of nerve and aesthetic complications in a 25 year old?

A: Thank you for detailing your cheekbone reduction surgery history and the not uncommon postoperative sequelae of some soft tissue sagging. In short I think the surgeon you have seen as summed it up nicely and the logic of coming to some form of midface lift is both logical and practical in your situation. While the potential complications to which you have described can occur, they are not ones I have seen, albeit one time on one side, and would not be the issue that would be of primary importance in making the determination for further surgery. I would be thinking about what are the chances of success in lifting the cheek tissues in a young person who does not have a tissue sag due to aging with naturally tighter tissues and the risk of undergoing an operation that may not work as well as you would like. It is important to remember that all facial lifting operations have their origins in aging patients with loose tissues that have lost elasticity. Trying to accomplish a real cheeklift in a limited exposure procedure in a young person does not work the same as in the older patient.

in short, I consider it a low risk procedure for medical complications but a higher risk one for truly correcting your cheek sagging problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read a couple of your answers to questions about the mentalis muscle, and I was hoping you could help me. I had a chin implant place intra-orally a few years back. 

A doctor on ReaSelf said that in all intra oral chin implants, the mentalis muscle attachment must be cut in order to place the chin implant which causes the muscle to sag later in life. 

Is this the case? Will my chin start to sag because the attachment was cut? Could you help re suspend the muscle if it is a problem? Thank you for any info you can give, I’m very concerned about this. 

A: While it is true that all intraoral chin procedures (implants, sliding genioplasty, bony reshaping) requires cutting through the bony attachment (origin) of the mentalis muscle, it is put back together during the wound closure at the completion of surgery. I can only assume that was done in your case because you do not have a chin sag now… as if it was not you would have a chin sag now. I have no idea why a surgeon would say it would sag later….as that is not true nor is there a biologic explanation for that statement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently doing braces for a year. I am sure you can’t do a genioplasty or customized jaw implant just yet. However is it possible to make a customized jaw implant that is designed to make a thicker and protruding mandible angle completely outward to create a sharp jaw line and a square chin implant? Also I am interested in a revision otoplasty. 

A: Good to hear from you again. Being in active orthodontic care with braces in place is not a contraindication to any type of aesthetic jawline surgery albeit a sliding genioplasty or a custom jawline implant since the teeth are not being manipulated in the surgery. Many of my patients for such surgeries are in orthodontic appliances which do not pose intraoperative surgical restrictions nor influence the aesthetic outcome. They are merely metal or plastic applicants on the teeth. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Congratulation for your surgeries. I saw on your website the earlobe rotation by the fish tail technique. I did an otoplasty 15 years ago.

I sent you an e-mail Months ago and you suggest me to do an earlobe reduction with an otoplasty revision. But I’m still afraid to do another complicated surgery revision because i think there are many risks of a deformation of cartilage through the scar release.

So two months ago I did an earlobe reduction through a scar excision. The earlobes are a bit better as the surgeon reduced their width and height. (they were big) But didn’t rotate the earlobe, so they still protruding.

Finally, is the “rotation” possible just to setback a little bit my earlobe to the head? What are the risks? I think I need less than 0.5 cm of earlobe setback. 

A: Since the earlobe doesn’t contain cartilage, it requites skin excision to change its position against the side of the head. The fishtail excision is an effective method to bring the earlobe back closer to the side of the head. It is unfortunate it was not done as part of your initial otoplasty but it can still be done secondarily.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old and have always had long philtrum or at least just very minimal teeth show. I have no recession, my teeth are fine and my palate is wide. If I were to get the needed upper lip lift, it would kinda make the outer corners of my mouth sag downwards. Would it be possible to then also get my corners lifted to look normal, after an upper lip lift?

Also, I think all the sagging of my philtrum and upper lip makes my midface look longer than it actually is supposed to be without the excess skin.

So in theory, those two procedures would make the “lip line” or the line created where the lips “seal together”, be moved up, right? Making my midface appear shorter?

I hope this makes sense, if not let me know, so I can try to rephrase it a bit. Also let me know if you need some pictures, to get a better idea of my case.

Thank you very much!

A:It would not be uncommon to do a simultaneous subnasal lip lift and corner of the mouth lift at the same time for the very aesthetic reason you have described. If the corner of the mouthy are already low or downturned they will become more so when the central part of the upper lip is shortened.

Whether it will make your midface appear shorter is less certain. But a subnasal lip lift is one of the few procedures that may potentially have that effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a abnormal chin … it’s long and wide I would love to completely shave it cause I hate my chin…. if I could have no chin it would have been better… that’s how much I hate it… I been bullied because of my chin and now I’m ready to do something about it.

A: Thank you for sending your pictures. You have a vertically long and wide bony chin. There are different methods for reducing large chins but one method is an intraoral osteotomy method to remove a wedge of bone to vertically shorten the chin as well as narrow it. The bone would also have to be removed behind it to maintain a more normal mandibular plane angle. Your submental fullness would also need to be treated by liposuction as that will look fuller as the chin becomes smaller. The other treatment approach is to do the entire bony chin reduction from an incision below the chin. Each of these two chin reduction methods as their advantages and disadvantages. 

In addition, chin reduction is very challenging to perform due to the bony and soft tissues excesses that exist. Most patient will need a secondary touchup or revision to get the best result possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have thought long and hard about a skull implant revision and I’d like to go through with a revision on the left side. I tried my best to take pics that would show you exactly what I’m trying to describe… hopefully these will work. 

You can see a gradual rise from the center of my head on over to the left side of my head. I believe shaving or essentially reducing the thickness of the implant will do the trick. The other trick is how much should the implant be reduced? and how will it be reduced? Is there a way to determine how much should be reduced to achieve my desired shape? MRI/CT?

Also, we discussed several options and using the same incision… but I’d like clarification on the risk of infection. I know it is always a consideration, but I’d like to know if simply having a revision will increase the chance of getting an infection? 

The other topic we discussed was the approach. Has this type of revision been done before? And if so what approach was used then? I read on your site that patients at times ask for revisions… is there a percentage on how many achieve their desired state after a revision?

 I am very satisfied with the right side of my head. There is a small area that I can feel and wonder if it can be shaved down or reduced? There was a concern of thickness and I would not risk it if that was a concern. Just wondering. 

Thoughts? 

A: To answer your questions about a skull implant revision:

1) The original incision would have to be completely re-opened. It may or may not heal as well as the first time.

2) The entire implant will need to be removed to be hand carved for the revision.

3) There is no scientific method to determine how much it should be reduced. That is an artistic judgment.

4) Every time you place or revise any implant in the body the risk of infection exists. Just because it did not happen the first time does not mean it can not happen the next time. Each surgery involves a new set of risks that are independent of what happened before.

5) Whether patients are satisfied with any revision depends on the aesthetic concern being treated and what is being done.

That being said I will pass along to you two basic concepts about revisional implant surgery that I have learned in treating many patients:

1) If you are largely satisfied with an aesthetic outcome, the risks of manipulating implants for making small adjustments could turn out to be a poor benefit t risk decision.

2) There are no perfect implant results. Just like the natural human body there are going to be imperfections. Living with them offers the safest medical course of action.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting surgery to correct my facial asymmetry and I am curious as to how much it would cost for me. My main concern is the lower part of my face. My jawline and chin is uneven. The right side on my face (left side for you) is noticeably bigger than the left side (right side for you) of my face. Another top concern that I have is my nose. I would like to even it out some more, create a higher bridge and a more rounded tip. I am also thinking about maybe getting cheek implants or filler but that is not a top concern for me right now. I just want my face to be more balanced. I have seen some of your work online and on Instagram so that is why I am reaching out to you today. 

Thank you.

A: As to your facial asymmetry concerns the following are pertinent questions/decisions to be made that affect the type of surgery and its associated cost:

1) Which side of your face do you like better? If it is the bigger right side then the smaller left side needs to be built up. Conversely if it is the smaller left side then the larger right side needs to be reduced. These are radically different types of surgery.

2) Building up the nose can be done by an implant or a rib graft, which do you prefer? These are again radically different approaches to the same problems.

Knowing your answers from these questions determines the cost of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom facial implants of the jawline, infraorbital, and temporal Implants. My questions are:

•Will the chin part of my custom wrap around implant be inserted beneath the chin using the same incision site that was used for my current chin implant? I have read that inserting chin implants through the mouth carries the risk of losing lip feeling.

•Can you confirm that the jaw parts of the wrap around implant will be placed through the mouth?

•Can you confirm that the infraorbital-malar implants will be placed through the lower eyelid?

•Is there any risk of silicone implants becoming displaced by liquids within the soft tissues surrounding the implants in the future?

•Is silicone the best material to use for my goals?  What about PEEK?

•What is masseteric-pterygoid sling disruption and should I be worried about it?

•Will there be any loss of movement, muscle swelling, nerve damage, numbness or loss of sensation post-surgery with any of the implants?

•My biggest fear is scarring, I know Dr Eppley said the incision scar for the forehead widening/temporal implants in the hairline would be small and it would not cause missing hair but I need assurances as I have seen two reviews below which talk about bad scarring.  How wide and how long will the scars be in mm?

•Will I need to shave the side of my head for the placement of forehead widening/temporal implants?

•What other risks should I be aware of?

•What happens if the outcome does not turn out right or I am not happy with the result?  Can implants be removed 3 to 5 days post-op? 

A: In answer to your custom facial implant questions:

1) If you have a submental scar from a prior chin implant, that scar will be used as one of the three incisions needed for the placement of a custom jawline implant.

2) There is no other way to place the jaw angle portions of a custom jawline implant but through intraoral posterior vestibular incisions.

3) The lower eyelid incisional approach is the only way custom infraorbital-malar implants can be adequately placed.

4) There is no risk of facial implants being displaced by the normal interstitial fluid contents of the surrounding soft tissues.

5) Silicone is the best material because it can be precisely designed and made and is flexible which is critical for insertion through small incisions in the least traumatic fashion. Stiff materials are problematic for a wide variety of reasons including the much larger incisions and greater tissue trauma to place them.

6) Massteric sling disruption is always a possibility when any jaw angle implants are placed. Such risk is magnified if there is significant vertical lengthening of the jaw angle portion of the implant.

7) All placement of facial implants causes temporal swelling, muscle stiffness, facial distortion, and numbness around the surgical areas. Such expected soft tissue responses usually fully recovery within two months from the surgery.

8) The vertical hairline temporal implant scars are 3 cms in length and usually about 1mm wide.

9) No hair shaving is needed.

10) The biggest risks are aesthetic in nature and include implant asymmetry and lack of desired aesthetic outcomes. (too big, too small etc)

11) You should read the Revisional Surgery form and understand it in detail. No aesthetic outcome can be guaranteed despite the best effort of any implant design and surgical placement. Facial reshaping surgery with implants is the most psychologically challenging form of elective aesthetic facial surgery and can be very stressful for the patient. No revision of any implants are done for three months as the full healing process is not complete by then. You would not be able to tell anything about the final result at just 3 to 5 days after surgery when you are still very swollen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had recently posted a question on Real Self regarding diced cartilage grafts and that there is growing evidence that source of the cartilage has an influence on the longevity of the graft. You had kindly answered my question stating that it makes a difference where it comes from (below link). 

Could you be so kind as to advise which one would hold better in the long run if I am faced between using either ear or rib for DCF? I understand that ear curls, deforms or may shrink on the bridge but I also fear that rib graft will ossify over time. Which graft would give me a better chance of it being permanent.

A: When you dice a cartilage graft tin rhinoplasty the issue of shape maintenance is irrelevant regardless of the donor source…as that is the primary reason it is diced. It is done to both achieve the desired shape and prevent any long-term shape deformation. Whether the donor source has a major difference in longevity can be debated but what is most important is the volume of graft needed. For small nasal augmentation diced ear grafts may be fine but most nasal augmentations in Asian patients require more volume than  even two ears can provide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a picture of my nose. This is how it looks every time I smile today – I get a distinct white spot at the tip of my nose. It’s extremely embarrassing in any social situation, because it looks so unnatural and weird. I’ve had three rhinoplasties already. The two first ones were to lengthen my nose, with rib graft. After the first rhinoplasty I didn’t have this problem, but after the second when the nose was lengthen further – that’s when the problem arose. The third surgery was made as an attempt to correct this issue, but with no real success. My surgeon told me he just shortened it 1-2 mm and put some skin grafts on the sides of my tip in order for the tip to not look so pointy and white when I smile. But as I said, it didn’t help. Maybe the tip got a bit rounder, but that’s all, the whiteness every time I smile is still there as you can see on the photo. My last rhinoplasty was a little over a year ago. Now to my questions:

1) Do you think this issue can be fixed by shortening the nose back to the length it was after my first surgery (about 3-4 mm shorter than it is now)? Or do you think it can worsen the problem, since I’ve already had three rhinoplasties done to my nose?

2) Do you think a skin flap/graft will be needed to the tip of my nose in order to make the skin thicker there – or how would you approach this problem, technically? 

30 Have you come across this problem before – is it hard to fix? Do you think my condition is permanent or fixable? 

4 My original rhinoplasty surgeon told me to “pull” the skin of my nose tip 10 times x 10 times a day in order to stretch the skin. He thinks this will fix my problem, but I have been doing this for two months now and I can’t see any improvement at all. Do you think this approach is realistic/promising, or just a waste of my time? 

A:The blanching of the tip skin after rhinoplasty when smiling is very uncommon but I have seen it before. Since the tip of the nose is the most stretched out portion of the nose, when it is lengthened (I assume cartilage tip grafting was done) excess pressure is created on the tip skin when one smiles causing a temporary loss of circulation. Deprojectioning the tip would be the appropriate solution if one can feel a firm cartilage graft under it which would the source of the aesthetic problem. Since it has been attempted once to deproject it and it has not been successful I would assume that any protruding cartilage graft putting excess pressure in the tip has been removed. Further deprojection may be successful but if it didn’t work the first time I would no have confidence that it will the second time. (although not impossible) I would think that placing a small fat graft under the tip skin many be helpful since such a graft is soft and will help improve the circulation to the skin in the long run.

While the stretching the nose tip skin sounds reasonable and it is harmless, I would not think its continued use ameliorating your nasal tip concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you very much for the effort that you have put in to illustrate the estimated outcome of the temporal reduction procedure in my son. I have had a conversation with a surgeon, and he said that narrowing the skull is not possible because it compresses the brain, and I really do hope that this is not the case and that a potential surgery like this does not risk the health of my adult boy in the future.

A: The imaging results I have shown you are based primarily on temporalis muscle reduction with some external bone removal. This is an extracranial operation not an intracranial one. So whatever surgeon suggested to you that it can not one done due to brain compression is misinformed. Most people, including doctors, do not understand that the temporalis muscle makes up a significant amount of head width above the ears with a lesser contribution from the thickness of the bone. It is both a safe and effective procedure that poses no long-term issues for brain or skull growth if done in younger patients like a teenage boy. It also poses no functional issues such as difficult with lower jaw function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping surgery. Please see the attached picture. I hope this provides an adequate image of my skull shape despite my current hair length (note my hair is very wet and patted down in these images). Please let me know if more shots from different angles would be beneficial. As you can see, my sagittal crest is very pronounced and is noticeable even with a full head of hair. I am looking for a smoother ‘outline’ of the skull, visible from both the front and side perspectives. I am hoping that the bone is dense enough in this area to allow for maximum reduction.

A: Thank you for sending your pictures. What you have is a combined sagittal ridge with a parasagittal deficiency. (actually the parasagittal deficiency is they bigger problem, it only looks like a ridge because of it) This is why sagittal ridge reduction (see attached imaging) of maximal amount (7mms) is woefully inadequate to treat the problem. What you really need is a combined sagittal ridge reduction with parasagittal augmentation. (see attached imaging) The parasagittal augmentation also needs to extend around the back as you have an upper parietal skull deficiency as well. (see attached imaging) Before I saw your pictures I knew this was going to be the overall skull shape problem because, when it showed through one’s hair, it is always more than just an isolated sagittal ridge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a tracheostomy scar revision for my wide and depressed neck scar. , In regards to tracheostomy revision using dermal fat graft…I am considering having this operation done, as I have a tracheotomy scar that has a dramatic upward retraction when swallowing or talking. I just don’t want to make it worse! Thank you for your time, I appreciate it. My questions are:

1. How many operational procedures are needed? 

2. How long does it take to heal from the operation? 

3. What is the size of the incision that is made on the neck scar? 

4. In your experience, what (approximately) are the success rates? 

5. What could go wrong with having this procedure done? 

A: The concept of fixing any depressed scar with a combination of a dermal-fat graft and scar revision is not a new concept. By definition any depressed scar is always a combination of a wide scar and tissue deficiency issue. In answer to your questions about treating a depressed tracheostomy scar revision with a dermal-fat graft:

1) The goal is one operation to ideally fix the problem. In some cases a touchup of the outer scar may be needed.

2) Healing is quick and I would not say there is really much recovery to it. The neck scar area is small as well as the body donor site for the graft.

3) Usually the size of the neck scar is no wider than one’s excising neck scar.

4) I have not seen any dermal-fat graft failures to date.

5) Short of an infection (which I have not seen) or loss of the fat graft (which I have not seen), it is not a procedure where there is much to lose by doing it. It is just a question of how much better can the neck scar become.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I am interested in mesh chin implant removal.  I had a mesh chin implant placed six months ago. It made my face look too long and I want it taken out. My doctor said he had a 50/50 chance of damaging a nerve or making my chin worse. Do you remove these and if so how many and with what kind of results?

A: I assume when you say ‘mesh chin implant’ you are referring to a mersilene mesh chin implant. I have removed several as they are not a very common material used in chin augmentation. With mesh chin implant removal, if you are not putting something back in, it is important to know that there is a risk of chin dimpling afterwards because the tissues have been stretch out and now there would be nothing underneath it as the chin tissues shrink back down. That may not occur depending upon its size but that is the one aesthetic risk I would be most concerned would occur. The other option, if the issue is that it has made your chin too long is to remove the bottom portion of the implant to shorten the chin as this will keep support to the chin pad and you are not concerned about excessive horizontal projection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reconstruction. I suffered a self inflicted blunt trauma to my right cheekbone ten years ago. I pushed it in with my fist over several months until I felt it sink in then stopped immediately. Not the zygomatic arch but around the orbit of the eye. The bone has healed and my face now appears asymmetrical. Ever since that injury the eyesight on my right eye has become somewhat blurry and I feel light pressure against my eye when I open my nostrils. I remember the exact day I felt my cheekbone sink in, the poor vision began. My left eye has perfect 20/20 vision. I was wondering if a right cheekbone osteotomy would restore the original symmetry of my face and take the pressure off my eye? Possibly restoring my vision. This was a terrible mistake that I made as a child and know how ridiculous it seems. Thank you. 

A: Without a 3D CT scan to determine the shape of the orbital walls it would be impossible to say whether any cheekbone reconstruction would improve the feeling of pressure in the eye or your vision. Although it could probably be predicted that no form of orbital decompression will cause improvement in your vision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in male cheek augmentation. I had all but decided against cheek implants as they often look like this.  He looks much more feminine after. However I just happened upon this result of yours from earlier this year which is making me reconsider.  I would love to have a brief conversation with you about 

1) Pros and cons of filler vs implants.  Is a result like this possible with filler?

2) What makes your result so much better than the result from other doctors?

3) Now that you have my CT do you think I might be able to achieve a result anything like this?

A:In answer to your male cheek augmentation questions:

1) All standard cheek implants are really designed for women. So when put in most males they are going to feminize the face by creating fullness in the apple cheek area…which is not what most men want to achieve in my experience, particularly young men. (and actually most younger women today don’t want that look either) What men who consider cheek augmentation are seeking is a high angular look that sweeps back across the zygomatic arch. Standard cheek implants can not create the effect.

2) As a result, most cheek augmentations I do use either a custom implant approach or a special design method. (use another patient’s custom cheek implant designs)

3) Fillers can not usually create the sane effect as implants. But when in doubt there is no harm in doing fillers first as a trial which can give a hint of the effect and, if disliked, will be resorbed with time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull implant. My head is very flat at the back. I would like to know what the advantages and disadvantages of using silicone vs. bone cements are. Particularly, how long they will last. I am 37 years old and hope to be around for many more years so need to know if these implant materials will last indefinitely. Also, is there a limit to how much material can be used to expand the back of the head as I estimate that I would need at least 2cm of posterior expansion to give a good cosmetic result. Finally, what is the approximate cost of such a procedure. Thank you.

A: Thank you for your skull implant inquiry. In answer to your back of the head augmentation questions:

1) Both bone cements and silicone skull implants are solid non-biodegradable materials that will last forever.

2) Custom silicone skull implants are much better than bone cements in my experience as they offer an improved amount of augmentation that has a much more assured contour and smoothness and can be placed through a much smaller scalp incision.

3) If you are certain that you need a 2 cm occipital augmentation, the scalp can not stretch that much in a single procedure., When patients need that amount of skull augmentation anywhere on their head they will require a first stage scalp expansion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know more about surgery to correct facial asymmetry. The right side of my face is significantly higher than the left side. I’m from out of town so I can attach some pictures if that would help.

A: Thank you for sending your pictures. What you have is a right facial asymmetry that is complete and involves all facial structures from the eyebrow down to the chin. The right face is vertically shorter and every facial feature, albeit the actual eyeball, is pulled closer together which is why the right eyebrow is lower, there is ‘extra’ skin of the right upper eyelid, the cheek is smaller, the right nostril is less wide and shorter, the mouth corner is less wide with less vermilion and the right chin and jawline is shorter.

Like all facial asymmetry surgery the key is to  first make a list of the facial asymmetries from most important to least important and then devise a surgical plan accordingly. I always tell my facial asymmetry patients to pick three of them that is most bothersome and make them the top surgical priorities. I have my list of what I would choose but I prefer to hear what the patient has to say first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am curious to know if being on immunosuppression is a reason that I can not have breast augmentation. I am on 5mg of prednisone, Imuran and Plavix daily. I am unhappy with my breasts and is interested in breast implants. Is this something that can be done, or not while on those medications? Thank you for your time.

A: Being on immunosuppression is not necessarily a contraindication to breast augmentation surgery. The risk of doing surgery on these medications is not really one of implant infection but a medical one (adrenal suppression) to avoid a postop hypoadrenal crisis with an inadequate stress response to the effects of surgery and hypotension issues. Int such patients that risk is mitigated with supplement doses of steroids during and after surgery.

That behind said the dose of 5mg of Prednisone daily would not be considered significant enough to warrant the need for additional steroid coverage. The focus then becomes one of making sure that tissue healing would be normal and supplementation with Vitamin A and Zinc are well known to help lessen any adverse effects of immunosuppression therapy on collagen production which is paramount for adequate wound healing.

When it comes to the drug Imuran, the risk of complications by being on the drug must be weighed against the risk of a flareup being off of it. Since Imuran is a purine antimetabolite immunosuppressive medication the medical literature does indicate a proven higher risk for wound healing problems. Is this is one she can continue with before during and after surgery.

Plavix, however is a different story. I don’t know why she is on it as your medical history is not detailed enough to make that determination. But I would speak to the doctor who prescribed it to determine its absolute medical necessity. I would be very hesitant to do surgery in her unless she was off of it as that is a hematoma just waiting to happen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation done with hydroxyapatite granules at the end of last year. While the outcome produced some improvement, I have a very short lower jaw and I am looking for anbetter solution to vertically lengthening my jaw angles.

The question is in the case if I would like to have an operation with you shall I remove the hydroxyapatite granules which might be difficult or you can put implants on top of the hydroxyapatitite? I should mention that the maximum projection on the jaw angle is just 2.0mm.

A:You would need to augment your jaw angles with implants on top of the hydroxyapatite granules as they are very difficult to remove and have bone growth throughout them at this point. Given what is probably some asymmetry induced by the granules this raises the question of whether standard vs custom jaw angle implants would be needed. One approach is t burr down any irregular jaw angle surfaces and place standard vertically lengthening jaw angle implants, The other option is to have custom jaw angle implants made to account for any asymmetry and irregular bone surfaces caused by the hydroxyapatite granules. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am transgender and would like to feminize my figure. (transgender body feminization)

I have been putting on fat in preparation for a fat transfer to my butt and hips. I was worried having read on the internet that the fat can be lost over a period of a year and I would that very distressing. So I am thinking that I would like hip implants and a fat transfer from her upper body (where fat seems to sit when I put on weight) to my butt .(as this is where I would prefer fat to sit if I put on weight). It would be really helpful to talk this through. 

A: If one has enough fat to do a successful volumetric transfer to the buttocks this is always the first choice for buttock augmentation in lieu of implants. But be aware that gaining weight for the procedure, which many patients do, may not create sustainable fat/volume in the long run. Fat cells are being abnormally enlarged and reproduced in a body weight situation which will change after surgery. Thus those fat cells that survive the fat transfer process may not hold their lipid content when one goes back to their normal or physiologic weight. In short fat transfer to the buttocks (or anywhere actually) is not a predictable procedure and this is made even more unpredictable by gaining weight to do it.

But given that patients rarely have enough fat to graft with the buttocks and the hips, it would make the most sense to invest all the fat one has into the buttocks and use implants for the hips.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knowing whether I can have an extreme jaw angle augmentation. I will be having surgery to both advance and widen my jaw very soon. However, my surgeon does not use implants. In the attached picture I have a before and (predicted) after for the advancement, but I also morphed it to have my ramus/gonial angle improved and thus increase my facial height solely through my lower 3rd. I wanted to know if you believe the 2nd picture (right side image) is attainable through custom implants. Thanks in advance for looking at this.

A: Such a custom jaw angle implant design is possible as you can make anything of any size or shape in the custom implant design. But from a clinical standpoint such an extreme jaw angle augmentation change would result in masseter muscle dehiscence (the muscle can not follow the implant down and back so far) with resultant implant reveal. The square end of the implant sticking out beyond where the lower border of the muscle will be. (muscle bulge way above the square jaw angle when biting down) In short this is not an advisable jaw angle implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am happy to hear I am a candidate for a sliding genioplasty. I scheduled a consultation for next month to discuss more. Before then, I had two follow-up questions. I understand completely if this is too much for email and would need to be discussed during a consultation. I apologize if this is the case. I just thought I’d ask since the consult is a ways into the future.

1) I was hoping to not have such a scrunched up chin when looking down. I was also hoping to improve support to my lower lip so that it hangs less when my mouth is open (photos attached). Would a genioplasty help with these things?

2) I am nervous about two possibilities from a genioplasty – an overly pointy chin/deep mentolabial fold and a thinned/pulled down lower lip (photos attached). One of the key reasons I was hopeful for a genioplasty and not an implant was that I read on your website that soft-tissue changes were more predictable with a genioplasty. Could the above two results be mostly avoided?

Again, I really appreciate your time and your website as a resource.

A: 1) While in theory a sliding genioplasty could help improve lower lip support in some patients, I don’t think in your case that would probably happen. That tends to occur with large horizontal bony movement in patients with really weak chins who have significant preoperative lower lip incompetence.

2) With the relatively small horizontal bony movement you would be getting, a deeper labiomental fold is not going to occur. This is also aided by the vertical lengthening which often helps prevent a deeper labiomental fold from occurring., You can also hedge against that from occurring by grafting the bony step off of the sliding genioplasty with some demineralized bone granules.

3) I have never seen the lower lip pulled down with either a chin implant or a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am a 32 year-old male and seem to be dealing with progressive hemifacial atrophy on the right side of my face. While signs of the disease first appeared seven year ago, I have seen more significant atrophy over the past 12-24 months. To this point, the disease seems to only be affecting soft tissue with no impact on bone or nerves. I understand your primary treatment option for this is fat injections, and I am interested in understanding more about this treatment as well as other options. 

A: It sounds like you have linear scleroderma as your source of facial atrophy. No one understands why this occurs and there are no known proven or preventative treatments for it. The standard therapy is to wait until the disease has burnt itself out and then fat graft it. Fat injection therapy remains as a front line treatment for a stable disease condition. Whether one should attempt to treat it in its active phase is a matter of debate. But given it is one’s own natural tissue, there is little harm in doing so. Whether it can cease the disease and prevent further progression of it is unknown but theoretically possible.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I contacted you a little while ago regarding chin implants, and you felt that I had a horizontal deficiency of around 10mm.

My first question is whether larger implants like this carry any particular risks or pitfalls compared to the smaller ones. I was also wondering what kind of frontal view change I can expect from a standard/non-custom implant of this size. 

Thanks

A: Good to hear from you again. I doin’t think there are any increased risks with chin implants whether they are small or large. The increased implant load per se does not make them more prone to complications. The more relevant issue is with larger chin augmentations should they be done with an implant or a sliding genioplasty. (move the chin bone) for a more ‘natural’ chin augmentation and one that eliminates the need for an implant at all. That would depend on what type of frontal view change one is looking to achieve. If one wants to make their chin wider or even more square then only an implant can accomplish that frontal view change. If one wants to keep the chin the same width or slightly less wide then only a sliding genioplasty can make that frontal view change.

Dr. Barry Eppley

Indianapolis, Indiana