Your Questions

Q: Dr. Eppley, I am seeking brow bone recontouring from a brow bone fracture that I had two years ago. This was never fixed and had left me with a big indent in my brow. Can this be fixed?

A: Thank you for sending your pictures and the x-rays. What you originally had is a depressed frontal bone fracture that involved the frontal sinus and supraorbital rim. It remains as a displaced forehead fracture but a healed one at this point. It is no surprise that a neurosurgeon would want to do a craniotomy to lift out all the bone and get it back into anatomic position through a full coronal scalp incision. This would certainly be the standard neurosurgical approach. But I can understand why that would not be that appealing to you at this point. The alternative treatment strategy would be a brow bone contouring approach. Leave the bone where it is and apply an hydroxyapatite cement over top of the entire depression to recreate a much improved forehead contour. This is an appropriate strategy as long as there is no air leak from the frontal sinus or a CSF leak into the nose. (which I am sure there is not)(

The only debate about this contouring approach is the location of the incision. It certainly makes access easier and a more thorough recontouring can be done with the wide open exposure of the full coronal scalp incision. But that incision/scar may want to be avoided. The alternative incisional access is through one of your existing horizontal forehead wrinkle lines. This avoids the larger scalp scar. I have done this many times for forehead cement application and brow bone reduction in men. It is usually a scar that heals quite well since it is in a natural skin wrinkle which is only going to get more pronounced with time anyway.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I would be able to get an idea of what is able to be done about my face being completely asymmetrical. (facial asymmetry surgery)

This is something that has bothered me my entire life and is only making me more self concious as I get older. I feel as though one side of my face is drooped. It’s not just the eyes or just the nose… every single feature I have is completely different on the right side of my face in comparison to the left. This is made even worse by the fact I am an identical twin, only we’re not identical because I was born like this and she was born with a normal even face.

After plenty of therapy etc there is still no doubt in mind that I cannot keep this face for the rest of my life. Is it possible to get computer imaging of what my face would look like and what could actually be changed to improve it. It also seems as though my jaw is more prominent on one side of my face in comparison to the other.

Thank you 🙂

A: Thank you for your inquiry and sending your pictures. What I see that you need to improve your facial asymmetry is:

1) Right jaw angle implant

2) Right cheek implant

3) Right corner of mouth lift

4) Fat injections to the right face between the cheeks and jaw angle
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Please help! I want to change my long face shape!  (facial reshaping surgery)I’ve always dreamt of having a shorter face….heart shaped or diamond shaped with higher cheek bones and a more defined jaw. I have a double chin! Also it looks like I’ve broken my nose?? I hate my nose it’s quite long and have always dreamt of a small button nose but it wouldn’t suit my long face. Please help! Thank you excited to see what I would look like!

A: Thank you for your facial reshaping surgery inquiry. While you do have a long midface that is magnified by the fact that your lower/chin is short with fuller neck. While you can  not really shorten your face, you can radically change its shape by the following procedures:

1) Sliding Genioplasty – to bring the chin bone and its attached muscles forward as well as help thinning out the neck

2) Neck Liposuction – defat the neck and help create a better cervicomental angle

3) Full Rhinoplasty – straighten narrow and shorten the nose

4) Buccal Lipectomies – thin the face below the cheeks

5) Small Cheek Implants – add some cheek highlights

All these procedures together will create a much different facial shape as illustrated in the attached imaging. In reality the face is not getting shorter, as that can’t be done, but it changes its shape into better a aesthetic balance and proportions.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw surgery. I’ve had braces throughout high school. My orthodontist used spurs on the back of my top 4 teeth in order to stop my tongue thrusting. That was unsuccessful and he removed the braces. A year later I went to a different oral surgeon then the one who worked with my orthodontist to have my wisdom teeth out and he mention jaw surgery for my receding chin but wasn’t a priority then. Now my concern is cosmetic as well as functional. I don’t wish to get braces again but want to do things “the right way” to fix both. I do have an uneven and open bite as well as jaw pain. When I currently take pictures I thrust my lower jaw forward and I like the way that looks but I want something more permanent.

A: Thank you for sending all of your detailed information and pictures. I believe you may be confusing a lower jaw advancement (sagittal split ramus osteotomy, SSRO) with a sliding genioplasty. An SSRO moves your whole jaw forward and is primarily done to get the teeth to fit together. It often has a coincidental chin augmentation effect whose magnitude depends on how much the jaw moves forward. An SSRO procedure can not be done without pre- and post surgical orthodontics in the vast majority of cases. Conversely, a sliding genioplasty moves the chin bone forward but leaves the part of the jaw behind it that contains the teeth. Thus it does not improve one’s bite relationship and is only done for its cosmetic chin augmentation benefits.

To come remotely close to the ideal female jawline that you have provided you would really need an SSRO procedure combined with a sliding genioplasty to get that much chin change. Jaw angle implants would then need to be placed six months later. They key to this approach, as previously mentioned, is the need for orthodontics.

The non-orthodontic option, which leaves the existing bite as it is, is a combined sliding genioplasty with concurrent placement of jaw angle implants. Such a result will probably create an outcome that is about halfway between where you are now and the ideal jawline you have shown.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to have some information regarding aesthetic shoulder augmentation with silicone implants. (deltoid implants)

After a motorcycle accident when I was young, I broke my right collarbone and in the hospital the doctor decided not to operate the shoulder.

As a consequence the bone of the clavicle is welded overlapping with the aesthetic result of shortening the length of 3 cm shoulder.

Moreover, my body was already thin, and has increased the curvature of the right shoulder to the inside. 

A: By your description it is just the right shoulder which is due to the loss of projection of the shoulder due to loss of clavicular length. Your treatment options include:

1)  A camouflage approach with the insertion of a right shoulder deltoid implant or

2) Treatment of the source of the problem by clavicular lengthening by osteotomy and plate fixation

I would need to see pictures of your shoulders to determine if a deltoid implant would offer a reasonable aesthetic improvement.

The use of deltoid implants has its advantages over actually cutting and moving the bone depending upon the degree of location of the shoulder deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a condition called costo-iliac impingement syndrome where my right 12th rib tip sticks into he right hip due to a laminectomy and spinal fusion I had in 1973. Over time some scoliosis and gravity have made my condition very painful. How much does a procedure like this cost? Do you accept insurance? Are there any surgeons that you know of closer to my area in Dallas Texas? Thanks for your time.

A:  The 11th and 12 ribs point down 45 to 60 degrees from the spine unlike all the other ribs above them. It is easy to see with this natural anatomy that any condition that makes one had a tilt to their spine that the 12th rib could contact the hip bone.

Your 12th rib can be safely and effectively removed through a small back incision. This will provide complete improvement in your costo-iliac impingement syndrome symptoms. I will have my assistant pass along the cost of the surgery to you on Monday. We do not accept insurance. I would not know if there are any surgeons who can or would do this surgery in your geographic region. There may be, I just would not know who they would be.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve done some research on Facial Feminization Surgery and noticed your website. I am interested in getting some Facial Feminization surgery going forward. I’ve had plenty of surgeries done in the past. I’ve had 4 rhinoplasties with alarplasty and tiplasty, Jawline reduction with chin contouring, chin implant, cheek implant, brow bone reduction, upper blepharoplasty, upper lip lift, hairline lowering, bone cement into forehead. I am not satisfied with how my jaw looks because it doesn’t look “normal”? I had my jawline reduction with chin contouring in 2012. I am not sure if I should consider a jaw implant? Also My chin implant looks masculine in my eye, I was hoping for a more feminine chin implant. I feel like my jawline is too curved if you know what I mean. I guess, when I told my surgeon I wanted a V-shaped face. He gave me that. I am interested in Kim Kardashian and Kylie Jenner’s jaw shape.

A:Thank you for your inquiry. With v-line surgery the jaw angles are removed and the chin is theoretically narrowed. (usually without an implant) This why your jaw line is ‘too curved’ as the angles are now too high. The chin implant that had placed is most likely a ‘male’ chin implant which makes the chin too wide rather than more narrow.

Ideally it would be nice to see an x-rays of your jawline to appreciate its bony contours. But to change the shape of your jawline your would need vertically lengthening jaw angle implants and replacement of your existing chin implant with a more feminine heart-shaped chin implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in pectoral implant revision surgery. I currently have pectoral` implants. These were custom made to my specifications. I had a larger implant made for more projection.I am fairly happy with them except they are too firm and they do not feel natural when massaged. I was wondering if there is such a thing as custom pectoral implants that can be designed to be inflatable with saline or silicone? I want somewhat firm implants although I wish the implants to have some softness to them as to mimic a pectoral muscle. Thanks for your assistance with this question.

A: While I don’t know the manufacturer and durometer (scale of stiffness used in silicone implants), it is very possible that new custom pectoral implants can be made of very low durometer that really mimic muscle tissue. This ultrasoft durometer of silicone is what I use on all custom body implants. This may be what you have in (although I doubt it) but I would need more specifics about the implants you have in to better answer that question. Most certainly you do not want a saline implant which would be worse than what you have now.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Would gummy smile surgery consist of all four elements below? Or sometimes only some of them?
1.  V-Y procedure
2. Muscle release / levator muscle transection
3. Using a premaxillary implant after muscle release
4. Vestibular shortening.
I understand (1), (2) and (3). However, I am not sure I understand (4) Vestibular shortening. What is that?
Do you need to examine my mouth before you can determine whether an operation is possible?
How long will I have swelling after surgery? 
Is the swelling visible to others after 4-5 days?
Success rate
What is the success rate? Is there always success in the treatment?
Alternatives
I do not want a botox treatment, because it is temporary.
What is your opinion on Lip Lowering Surgery? Do you use it?

A: In answer to your questions:

1,2 and 4 are always done in Gummy Smile Surgery. A premaxillary implant is rarely used unless one has a premaxillary deficiency.
A Gummy Smile surgery can be done on anyone with a gummy smile. Seeing pictures of your face and seeing it at rest and smile is the examination that is needed.
Most of the swelling will ben gone in 7 to 10 days after the procedure.
There is always going to be some permanent improvement, it is just question of how much. I have never performed a revision on such surgery to date.
Lip Lowering Surgery is the same as a vestibuloplasty. It is part of every Gummy Smile Surgery

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I hope this email finds you well. Next month will mark one year since I had my custom jawline implant augmentation surgery with you. To say I am happy with the results is an understatement. I think you did a fantastic job in selecting and placing the implants.  Here are recent pictures.

As I mentioned, I am very very happy with the results. I just have one question. I have been working out quite actively over the past year, and I am almost 20 pounds heavier (mostly lean muscle) than when I saw you last year for my surgery. I’m still working out and continuing to change my physique so I wouldn’t want to do anything just yet, but my question is as follows: Do you think I could get another augmentation to make the jawline more pronounced? I would think the implants would need more width as well as more of a vertical component. Also, would I benefit from perioral and/or buccal fat removal? 

Thanks again and I look forward to hearing from you.

A:Thank you for the one year followup and I am very happy to hear of your satisfaction with the result. For your and my interest I have attached your matched before and after results from your surgery.

The question about replacing your existing custom jawline implant with a new one is not whether it can be done (as it can) but whether it should be done. From that perspective I would offer the following comments to ponder:

1) Would you be keeping this new physique lifelong? You wouldn’t want to place a new implant now for your current body shape and weight only to get thinner later and have it look too big. 

2) Any implant surgery is a gamble both in the aesthetic outcome and in the potential for risks. You have spun the roulette wheel twice so to speak and have won each time. But that is not an assurance that doing it a third time would result in such good fortune. Complications can and do happen…and such a complication like an infection could risk losing it all. Statistically speaking, each new surgery is an independent event for which the outcome of past events has no relevance.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, When an individual gets revision for sliding genioplasty, three to four months after initial procedure, and the same cut that was used in the initial procedure is traced and used again for the revision? is bone freshening a requirement? 

Meaning do the end segments of the bone have to be “freshened” or can the cut simply be traced and reused without such practice taking place?

I think I remember hearing that freshening the bone segments or doing ‘something’ with them (can’t recall the exact maneuver) is necessary if nonunion is to be prevented. Is this true?

A: In a sliding genioplasty revision  you have to make a fresh bone cut. In essence the exact original procedure is redone if the procedure is done after the bone is healing. (6 to 8 weeks after the first surgery)  I assume this is what you mean by ‘bone freshening’. Before the bone is healed, the down fractured bone segment can be simply unscrewed,  repositioned and then resecured.

Usually one doesn’t have a good idea as to the final result (3 months afterward) until the bone is healed. So most sliding genioplasty revision procedures require a new bone cut to do.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I currently have custom made cheek, chin, and jaw implants and I feel they are too big overall and I would like your opinion on replacing them. 

I have had numerous facial procedures over the last 25 years, and I am pretty happy with how they turned out, but the facial implants miss the mark each time and have been re done a few times.  As you can imagine, I am very nervous about potentially going through this again. I think my mistake has been bringing in photo’s of celebrities that look nothing like me and trying to achieve a look that is unrealistic.  I would like to just look like a hot version of myself:)  I have also not been cognizant  enough of each doctors aesthetic, and I have not been hands on enough when the design of the implants have been planned. I’ve just left it up to the doctor to produce them after explaining what I would like.  I would want to be involved in the process and think things through very carefully.  
My specific concerns/questions:

1. I dislike the cheeks the most. While I love the look of high cheek bones, I feel there is too much projection to look natural, and the emphasis is near the sides rather than the apples of the cheeks where I would prefer it. They are submalar which I think make my cheeks look too puffy. I would love a more sculpted, defined look (but not gaunt). My cheeks bunch up when I smile and I have some very slight aching in my face. 

2.  The jaw implants are a little too big.  I would prefer a softer, more feminine angle. 

3. The chin is a bit too large and square.  I would really like to go back to my natural heart shaped face and more delicate chin.

4. Would I need a facelift after removing such large implants?  I’m 49 and that is one thing I have not done.
I have attached photo’s of myself currently as well as my before picture and what my goal face looks like.  I understand you are not a magician, but it gives you an idea of what I would prefer. 

I really appreciate your time.

A: Thank you for sending all of your pictures and images. I would certainly agree that you should approach any further facial surgery with both caution and skepticism. When custom facial implants do not produce the desired result, it is always only due to two reasons… either the design of the implants is inadequate or the end goal was never realistic regardless of the implant design. In looking at your current face and now and what your goal is….that is a smaller and more refined facial look/angularity. I would think taking your face from where it is now to anything close to that desired look is not realistic. It is easy to make a face bigger with implants but it is never easy to make a face much smaller as the overlying thickness of the soft tissues now has a major impact. But to answer your specific questions:

1)  I would agree that your cheek implants are too bit and cover too much of the maxilla. (I am not sure why they ever covered the maxilla at all actually)

2) Your jaw implants are actually relatively small. But they are anteriorly placed and are designed to be a widening style. What you actually need is small vertically lengthening style instead.

3) Your chin implant is very small and thus should not be there at all. If you want a smaller chin you would need to remove the Implant and reshape the bone.

4) I see no benefit to a facelift for you. Loose or sagging skin is not an issue you have.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant revision with size reduction. I got large breast implants when I was younger but now they are too big and give me back and shoulder pain. I wanted them replaced with smaller implants. I want smaller and more perky breasts now!

A: Thank you for sending your pictures. There is never a problem with downsizing your implants. The question is what happens to the enlarged skin sleeve… as it will just drop and sag. In the spirit of what you really are trying to accomplish (smaller breasts with less pull on your back/neck) you would have to have a breast lift with smaller implants to really get that effect. Smaller implants alone will not be enough. You must get the enlarged breast tissue and skin back up on the chest wall. This is really no different than a true breast reduction patient. Just that in the augmented patient, the breast ‘reduction’ comes from either downsizing or removing the indwelling implants.

It is easy to make a breast larger with implants but it is not so simple to get a well shaped smaller breast by just downsizing or removing the implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, So basically what I would want ideally is to get my waist and love handle- area reduced by liposuction and to fill in my hips where the sort of dent in right at the top of my thighs. I want the arch where my butt begins at my lower back to be more defined and I want the overall appearance of the entire butt to be quite a bit bigger and fuller. Basically the hourglass shape is my ideal body! I also would really like to know if harvesting fat from my arms would be feasible. I have been an athlete my whole life and have tried every diet and workout plan to loose fat in my arms and they just always stay big. They’re by far my biggest insecurity and I would love if we could address them if posssible.

Thank you!!

A: Thank you for sending your pictures. What they show is the following based on your objectives:

1) You would be able to get a good waistline and love handle reduction by liposuction.

2) While arm liposuction can be done, it never creates a substantial size reduction. The improvement would be far more modest.

3) You have enough fat available to fill in the hips dents.

4) You do not have enough fat to create the ‘entire butt to be quite bigger and fuller’. Whatever fat is left over after using it for the hips can be placed in the buttocks but that will not be enough for any significant buttock size increase.

5) Buttocks always look bigger because of the waistline reduction above it in BBL surgery. But it is a not a realistic goal to achieve a much larger buttocks with the limited fat you have to harvest.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m 18 years old and have saved up for a few years for a procedure I’ve always wanted done, changing my eyes shape. (eyelid reshaping)  I’ve done a lot of research on the type of procedure. The catch is that my eyes already have an upward tilt to them, I want them to curve them downward. Can you explain to me if this can be done.

A: What you don’t like about your eyes is that the lateral canthal position is quite high. Rather than having a horizontal inner and outer eyelid corner position, your outer eyelid corner is angled upward. This is a more typical of some types of Asian eyelids and very uncommon in Caucasian eyelids. The only way to change that tilt and potentially bring down the lower eyelid position is by repositioning the lateral canthal tendon position. This may level out the eyelids but will not necessarily give a rounded eye appearance, increase the amount of scleral show or make the eyelids look less ‘squinty’. It may have some positive effects in these regards but they can not be precisely predicted before surgery. Bringing down the outer corner of the eye is much less commonly done than trying to raise it but it can be done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in extra large breast implants. I now have 2500cc saline implants and my wish is to come to 3000 or over. I want my breasts higher, more together in the middle of the chest. Now they go outside to the sides.. Before my current saline implants I had silicone breast implants. My wish would be to go back to silicone but at that size is it impossible or in Germany a Dr say to me you could put two implants in one breast ?

So my question to you : you would make a surgery in the size ???

I have no internal bra .

Many regards

And what is your suggestion to reach my aim ?

A: Thank you for your inquiry. I would need to see pictures of your breasts to give a more qualified answer.

But what you want to achieve is both challenging and many not be possible. Ideally what you need is a silicone implant of that size with a broader implant base. Nowhere in the world that I am aware of are silicone breast implants made greater than 1500ccs. While stacking implants has been done it is recipe for complications and breast deformity so I would not recommend that approach.

Regardless of the implant size you would have to get the breast mounds higher which can only be done, partially, by an internal bra approach. Any form of true external breast lifting has unacceptable scars. But with such large breast implants getting the breasts up and closer together is virtually impossible due to the implant volume.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Thanks for your email and all the helpful advice. A lot of what you told me was new information to me and I attempted to do further research for myself but, for instance, in regard to a mucosal smile line reduction, all the relevant info posted online that I could find was written or published by you, and pretty much you exclusively. Since you seem to be an authority on this procedure and if you don’t mind, I have a few questions.

Some of the things I had questions about were as follows: 

-In regard to the smile line lift, how does this compare to a lip lift? How would a procedure like this affect the way my lips/smile look, ie, would they appear bigger, smaller, etc? 
Would it affect at all the aesthetics of the rest of my face? Do you have any photos that you are able to share with me that would demonstrate this?
 What do you think the chances of getting results of showing more upper incisors would be, and do you feel that this would be the best way to improve the cosmetics of my smile/face as opposed to some other operation, such as orthognathic surgery, or a totally different issue that needs addressed other than lack of incisor show, etc?
-In regard to a midface deficiency, I also have dark circles under my eyes that seem premature. 2 years ago my sister died and then last year my lifelong best friend died as well, and since those events I’ve noticed the darkness appear to get darker accompanied by fine lines, which I’m presuming had to do with a combination of stress and the natural aging process in my 20’s. Do you think I would benefit from either malar implants or fillers in my cheek area? Do you think I am too young or otherwise not an ideal candidate for a lower blepharoplasty, as from what I’ve seen online it seems to have good results for preorbital discoloration like mine. Furthermore, IF you do recommend cheek implants, do you suppose that it would affect my smile in itself by pulling the skin upward or would the anatomy not be affected in this way?
I’ve attached a few additional photos with this email that specifically show my smile/teeth from a front as well as side view should you find it helpful. 

Thank you so so much for all your helpful insight, it is very useful for me to get an idea of what my best options would be, and much appreciated

A: In answer to your questions:

1. A smile line lift will, by definition, make your upper lip look smaller and will not change the vertical distance between your nose and upper lip. Conversely, a subnasal lip lift shortens the vertical distance between the nose and lip, makes the central upper lip look bigger as well as increases tooth show.
2. Due to patient confidentiality I do not pass patient’s surgery results by email.
   Lip lifts and orthognathic surgery are done for completely different reasons, they are not comparable procedures.
3. At your young age you need to either try injectable fillers or fat first for under the eyes and/or cheeks. Implants are only a consideration based on those injectable and reversible outcomes.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions concerning forehead implants. 
1. what are the implants made out of? and is it possible for them to break?
2. do the implants need to be replaced and do they feel like your natural bone once they’re put in place? and. 
3. can you choose the shape you want your forehead to be?
thank you 🙂

A: In answer to your forehead implant questions:

1) Most forehead augmentations today are usually done with a custom implant approach made from a 3D CT scan. The implant material is silicone of which it is not possible for it to break or degrade/breakdown over time.

2) Forehead implants will feel firm just like your natural bone. They will never need to be replaced for implant failure or degradation since that does not occur.

3) As part of the custom design process, forehead implants are designed as best as possible to meet the patient’s aesthetic forehead/brow bone shape desires. They are designed based on what the surgeon interprets as the patient’s forehead shape goals. The computer can not take the patient’s desired image and make an implant that will match that exactly. It is up to the surgeon to make that ‘artistic’ translation from patient desires to implant design. 

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, With the forehead augmentation, does that include the space between the eyebrows? Do your forehead muscles heal over the bone cement? Could it be placed on top of brow bones or will that be risky because its too close to the eyes? How old do you have to be to get it done? and will it tighten the skin on the forehead and eyelids (if you apply it to the brow bones)? Sorry for too many questions 🙂 I just want to get the surgery done in a year or so but I can’t find specific information.

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

1) In forehead augmentation the design and location of the augmented areas is determined by the patient’s aesthetic goals.

2)  Augmenting the brow bones as part of the forehead augmentation is common.

3) Age is not relevant to the procedure, it can be done from the teenage years to old age. The desire to do it is the only limiting factor.

4) Any forehead/brow augmentation will have some degree of upper eyelid skin tightening based on the size of the augmentation. But in general it has limited ‘eye lifting’ effects.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a lip lift done 2.5 months ago and I’m having complications. The tip of my nose is being pulled downwards when I smile and is very tight. 8 mm was removed from my lip and it is also very unnatural looking and high in the middle and thin on the sides. I posted on this site for help and no one has responded. I am depressed and desperate for answers. I thank you kindly in advance.

A: Thank you for sending your pictures. Your lip situation is one that is the result of too much central lip removal. It is now too short and tight. It usually takes 3 to 6 months for complete settling of the result but what you see is probably about 90% of what the result will be. You should be pulling on the upper lip regularly to try and stretch it out a bit.

A lip lift is an irreversible procedure. Once the skin is removed it can’t be put back. This is why upper lip lifts should be done conservatively, most upper lip lifts I have ever done have been between 4 to 5mms at most.

Your upper lip issues and concerns should be addressed by the surgeon who performed the procedure. There is not a surgical solution to these concerns.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a teenage breast lift. My daughter is 15. And she just lost over 150 pounds when she decided to get some weight off of her. She’s real insecure about her breasts though, they say they are just ” flabs where my chest is ” and ” no 15 year olds breast should be like that. So the real question is. How young is too young for you? I just want my daughter to be comfortable in her own body.

A: As long as she has maximized her weight loss, (and I would think that at over 150lbs she has done so) then she could have aesthetic breast surgery at any time. Even at 15 years of age, her breasts are not going to grow nor are they going to change in any favorable way. And give her understandable insecurity I see no problem with her age for whatever breast surgery (lift, implants or both) would make her feel more comfortable with her body. While teenage breast lifts are uncommon, your daughter’s situation sounds very reasonable to have the surgery even at her young age. The only question is whether she would desire implants for more volume at the same time.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a jaw angle implant revision.I want to remove both pairs of indwelling jaw angle implants and replace with new true vertical lengthening jaw angle implants. 

In your website, I saw the vertical lengthening jaw angle implants. I am not sure if they come in different sizes. I am positive that Vertical Lengthening implants are what I should have had implanted in the first place.The trick would be deciding on the size. From the profile view, you can see that the vertical length isn’t bad. The bottom part of the implant does go vertically far enough, but there is no mass at the bottom. This makes me wonder about the size we would have to use.  

The first Medpor implant did not have any effect from the front view. It did make a difference from the side view, though.  In my opinion, the picture where I’m sitting in the car, it shows that a could use some vertical lengthening and widening in the lower part of the face. I am not looking to have a very strong jaw, but in my opinion, it makes a big positive aesthetic diferrence when the angle is visible from the front view. It defines the face. 

A:Thank you for the additional information. Not knowing exactly what style and size of Medpor jaw angle implants you have in and where they really are sitting on the bone makes it very hard to know whether this is truly an implant style/.size problem or whether it is more of an implant positioning issue. A jaw angle implant can look quite different based on where it sits on the bone. You can’t tell just by looking on the outside either of those important issues which play the determining role in what new implant may be needed in your revisional jaw angle implant surgery. Therefore I would recommend you get a 3D CT scan so you can really know what you have in, where it is on the bone, and then know why it looks like it does on the outside. Just guessing on the implant exchange is a sure way to end up with another aesthetic problem…and the next surgery will likely be just as traumatic as the first as getting those Medpor implant out is never easy.

You also have to consider one potential reality is that maybe no jaw angle implant shape or size can give you that exact look you have imaged. While I would agree that is a good look, actually getting there may or may not be possible.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a reverse browlift. Seven years ago I had an endoscopic brow lift that left my medial brows too high. I had a brow reversal done (coronally) to bring my brows back down to my natural position. My brows were brought down 3-4mm but only lasted roughly 48 hrs before working their way back up again. Apparently the tacs that were used for this surgery did not hold.The Dr thought it would be ok to give it another try- I was super excited and couldn’t wait for my revision.. Although I had stitches from ear to ear and two pumps hanging down my head for a couple of days the surgery itself was practically pain free. Needless to say the second surgery (3 months later)left my brows on top of the bridge of my nose instead of on the inside where they sat naturally.

I look very unnatural still- my eyes have taken on a roundness and I feel I’m a bit cross eyed and my eyesight has suffered not only from an overly aggressive browlift but at the same time seven years ago I had an overly aggressive blepharoplasty as well. My lower lids have retraction. The Doctor who performed my brow reversal also did a canthopexy which has failed as well. So if you could just imagine my medial brows raised and my lower eyelids dropped.

I am asking you this question: could it be possible to place eyebrows back down on the inside of the nose with a device to keep them there? Thank you for your time.

A: Thank you for your inquiry and detailing your browlift history. When it comes to trying to reverse a browlift, a superior (coronal) approach is never going to work. That could have been predicted beforehand. It is not a function of the ‘tacs not holding’, it is a function of that it is impossible to get a downward pull on the eyebrows from above. It is a little like saying you want to lift your eyebrows from below…this is simply not going to work. To get the proper inferior vector you have to come from below (upper blepharoplasty incision) and put your point of fixation on the BOTTOM side of the medial brow bone. This provides the proper vector of pull. This also explains why the last effort created ‘left your brows on top of the nose’ as the pull could only created an inner or medial pull not the needed downward pull.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I am 7 mos post-op from a primary rhinoplasty and hoping to have a revision as soon as possible. I have heard great things about you and your practice. My surgeon did not correct the profile and make it straight as we had talked about. The objective was just to lower/ straighten the bridge and do minimal narrowing to the supra tip without touching the tip. The only difference I saw after the cast came off was that he may have narrowed the supra tip slightly. I couldn’t smile initially, but as I began to get more movement back I noticed a crease that looks like a mustache when I smile. I asked him if he released a muscle at the base of the nose and he said no. It was an open rhinoplasty though. 

I just visited another doctor who who saw me before the procedure as well. He was not very encouraging about whether the crease could be eliminated, and saw no difference in my before and after images besides 2 bony lumps where it was broken and not rasped at all. These were more obvious after my surgeon used steroid shots 3x (I don’t have pics of this.) We did not continue with the shots since since I didn’t want to thin the skin further. My surgeon didn’t know what could be causing the crease, but acknowledged the bony lumps as “irregularities which may eventually warp the nose.” He said “time will tell,” but would not comp any part of a secondary surgery even though there was no positive change to my profile. I’ve attached before and after pictures for your review.

I would very much appreciate any suggestions you may have. Thanks and hope to hear back soon!

A:Thank you for sending your pictures. I think it is very clear that you got no reduction at all in your dorsal line/hump…which seemed like it was the major point of the rhinoplasty. Not sure what was done in the surgery that did not make that happen. But that is irrelevant now and could definitely be done at any point.

As of your upper lip crease, an open rhinoplasty incision by itself does not cause that issue. Modifying the caudal septum with depressor muscle release can but that does not appear to have been done. (particularly since even the bridge was not lowered) How to improve that now is vexing since its origin is not really known.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty 1.5 years ago and though it was predicted I still see quite large “edges” on one side, but actually both side of the face around the edges needs some kind of filling. My other issue is the deep mentolabial fold which is not the result of the surgery as I always had it, but I’m wondering if this can be addressed with some kind of further surgery or fillers etc. Also notice the “curved” end of the chin, I’m wondering what causes that?

A:You have all of the classic minor aesthetic issues that come from a sliding genioplasty of more than a few millimeters of anterior movement. Stepoffs at the back end of the osteotomy, deepening of the labiodental fold and a rounded anterior projection of the chin.  These are all due to the U-shape of the anterior jaw being pulled forward into a more narrow u-shape. There are a variety of augmentation strategies for the back of the osteotomies an the labiodental fold. The curved end of the chin can only be proved by placing an implant in front of the bone. These are all strategies to use in a sliding genioplasty revision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about midface lift surgery. I read an article which described the following technique…’it returns facial volume to the upper cheek and lower eyelid area without the need for skin incisions (the two short scars are located within the scalp and mouth). Imbrication means “stacking,” as the deeper tissues of the lower cheek are stacked higher beneath those of the upper cheek. Midfacial suspension is accomplished by a single absorbable suture (this time a heavier “2-0” vicryl) positioned through the mouth incision, again without tension. Impressive improvements typically follow to the cheek, lower eyelid region, and mouth. Performed alone, however, any midface lift brings only limited improvement to the jowl complex, jawline, and neck, where most established aging resides. Therefore this “scarless” internal facelift becomes appropriate only in selected patients with earlier aging and fewer concerns about the jowl and neck region.’

My Questions: The last paragraph alludes to “limited improvement to the jowl complex, jawline and neck……”.  And that makes sense because you are pulling a lot of tissue/skin straight up, a long distance.  I was wondering if you would agree that a “short scar” traditional facelift might be the final piece of this puzzle?  It has been about 17 years since my original facelift so maybe there is merit to a vertical midface lift and traditional facelift.

A: Thank you for the additional information. While it is true that a midface lift does not have the greatest influence on the jowl area (it is  sheer function of distance from the point of pull), the author’s technique would be particularly limited because it is a midface lift that is done completely from inside the mouth and from below. (in effect a push technique) Thus it is really a very limited midface lift that is very different than the more traditional midface lift with cranial suspension. (a pull technique) These two types of midface lifts are not really synonymous/interchangeable in terms of their effects.

That being said, if one wants to cover all their bases so to speak adding an additional component of a tuck up lower facelift at the same time as the midface lift will provide some additional improvement along the jawline as well.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty. I am 18 years old and male. Although I am an adult it is pretty young to be getting cosmetic surgery. I have a weak chin that is probably caused by a recessed jaw also, but I really do not want jaw surgery cause my bite is good. The problem is since I am young I am worried about bone erosion. Do you offer any procedures/osteotomy that can square the chin? I like the benefits of a sliding genioplasty because it can help with breathing. But it makes the chin look more narrow. My chin is rounded. Is there any way to square the chin and bring it forward with bony tactics? Since I want other implants such in the future I would like to avoid it on the chin. So basically my question is do you preform or can you preform any osteotomy that will bring the chin forward and give it more of a square shape? Like width wise and not pointy. Thank you doctor.

A: A sliding genioplasty can be performed where the down fractured bone segment is split in the middle and expanded within an interpositional bone graft. This will create some degree of wideness and maybe a hint of squareness. But it will not create the square effect that a square chin implant can create. An alternative sliding genioplasty strategy, and a better one, is to place carved ePTFE implants that had squareness to the corners of the advanced bone. This is a blended strategy of osteotomy and implant that uses the best of both of them for a more square chin effect in a male.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making the ears more prominent (reverse otoplasty) from the front. My ears are barely visible, hiding behind my face at an odd angle and have always been insecure about it. I was wondering if it might be possible to to maybe build up the bone underneath the ear or any other method to make them come out farther than my face to an ideal angle? Thanks in advance.

A: Ears that naturally are back too far (minimal auriculocephalic angle) or those that have had an otoplasty that is overdone are treated in a similar manner. A reverse otoplasty technique is used where an interpositional cartilage graft is placed between the released antihelical fold cartilages. (cadaveric rib cartilage) This will push the outer helical rim outward and make the ears more noticeable from the front view.

This is an ear procedure that is done by making an incision on the back of the ear and exposing the curved cartilages. The cartilages are then scored to release them and a cartilage is placed between them to push the outer half of the ear outward. The key to success with this procedure is the interpositional cartilage graft. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull reshaping procedure. I have an odd shaped head that is long from front to back. I think I have a form of craniosynostosis that went untreated as a baby. What can be done now for it? I have attached pictures for your review.

A: Thank you for sending your pictures. As you know your head shape is a direct reflection of having had untreated sagittal craniosynotosis. This is why the back is so long and the forehead is slated backwards. While you did not include a front view, it is also likely that your head is fairly narrow in width as well.

What you may know is that it is no longer possible to treat your skull shape like is done in infants…a total skull reshaping by bone removal and expansion. That is done done in adults as that approach is reserved for when the bone is very thin and malleable.

This leaves you with several options. First, can the back projection be reduced enough to make a noticeable difference? The answer as to whether that is an option is how thick is the bone as this will require an x-ray to answer. Other options include upper forehead augmentation and skull widening but these may be not as important as reducing the projection on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wanting to know if you procedures for the upper eyelids (upper blepharoplasty) would qualify for insurance coverage. My insurance company said it should since it’s affecting my vision. I just wondered if you accept that. Just for the upper of course. Thank you for your time.

A: Whether insurance would pay for an upper blepharoplasty can not be determined by the patient asking them. It requires a complete written predetermination process submitted by the surgeon which must include visual field testing by an opthalmologist/optometrist that clearly shows visual field impairment as well as pictures that show sufficient hooding of upper eyelid skin. As a general rule it is very difficult for patients under age 65 to qualify today for what was once a common insurance coverage procedure. Only the insurance company can actually tell you based on the submitted information whether they would cover it or not. Talking to your insurance agent or the benefits office does not constitute an approval or whether it will actually be covered. They always say it will be covered ‘if there is a medical reason for the surgery’ when the patient calls and asks. But only the predetermination department of the insurance company can answer that question based on submitted information.

Dr. Barry Eppley

Indianapolis, Indiana