Your Questions

Q: Dr. Eppley, I emailed you previously about a lip lift I received from another doctor at the end of last year. I was very unhappy with the length of my upper lip  which has not changed since. I have another new issue now, my scar. It has come to my attention that it has recently widened and thickened. So now I have a terribly high lip, and also a terrible scar! It’s been a very terrible emotional roller-coaster for me, as you can imagine.

You were very nice and helpful when I reached out to you initially for your input. So i wanted to reach out to you again for your opinion on some research I’ve been doing to potentially help my situation.

I was wondering what you thought about performing a z-plasty scar revision on either side of my columella, the would essentially help thin out my scar, and ALSO potentially lengthen my upper lip, while partially camouflaging the scar within my philtrum creases (if this makes sense).

I’ve attached a few recent photos of my concerns, (sorry i don’t look overly enthusiastic in my pics!)…. I’m curious if you think this could work for me, of course in a few more months time (possibly a year), I do realize I’d have to wait before I do another surgery.

A: I remember your upper lip lift concerns from just a few weeks ago. While it may seem like an eternity to you, you are still very early in the healing process. I would not expect any changes in your upper lip length at this point. This is a process of 3 to 6 months, not 3 to 6 weeks after the procedure. The only thing you can and should do at this time is use your tongue to push out the upper lip under your nose as a form of upper lip stretching.

In regards to any form of a z-plasty scar revision, this is a procedure that lengthens scars by changing the scar line in z-shaped pattern. Besides the issue that this will not really be effective for upper lip lengthening, it will also creates more scars that would become even more visible than the scars yo already have. The philtral columns are not a crease but a raised skin ridge so this is not a good place to put any scars. Therefore, this is not a viable treatment approach for your concerns.

The most effective strategy for your lip lift at three months after surgery is to do either fat or PRP injections underneath the scar/nasal base followed a month or two later with a scar excision/re-closure. This will give your lip plenty of time to relax, drop a little  and give the tissues more healing time to  better respond to scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital dystopia correction. I am writing to enquire about the correction of my severe facial asymmetry that has been bothering me for quite long. I did not even think it was possible to correct uneven set eyes until I saw the before and after photos of the black gentleman you treated with orbital correction.

Please allow me to ask some questions: Did the former mentioned patient also receive a brow lift?  What procedures next to orbital correction will I additionally require if I want to achieve the best possible eye symmetry? Is the reduction of only one cheekbone reasonable in my case?

I look forward to hearing from you.

A: Your right orbital dystopia is associated with a low right globe, right upper eyelid ptosis and lower right lateral canthal position. But the brow position above the lower eye is not lower but symmetric to the opposite side.

Therefore the treatment approach would be orbital floor augmentation, right lateral canthoplasty and right upper eyelis ptosis repair. Whether the cheek on the affected side would benefit from augmentation as well can not be determined based on your submitted pictures. At the least it is less important than the other mentioned orbital dystopia procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fixing a problem that has developed after jaw angle implant surgery. Here are some photos of the area. The first is with my teeth clenched, and the second is when they are relaxed. The rest are an attempt to demonstrate the deformity with the light available in my living room. I would be happy to take more photos if necessary. 

The deformity was evident a few weeks after surgery, when the swelling subsided, and I was informed by the surgeon that the masseters would remodel. They have not changed. It feels to me also that the insertion point in the mandible is too anterior, creating a bulge in the cheek when really I wanted a hollow, and instead bulk posteriorly. 

I feel the position of the implants is great. The issue (to me) is that the masseter muscle does not sit over the angle of the implant. I feel like I have two mandibular angles.

A: What you have is masseter muscle disinsertion from the jaw angle implant procedure. In the process of putting in the implants the pterygomasseteric cling has become disrupted and now the masseter muscle has retracted up over the implants. This is a well known aesthetic sequelae from the pro cedure that does happen in some patients. It is not usually possible to move the masseter muscle back down over the implants, it is scarred and contracted upward. I have tried that procedure from a neck incision numerous times with variable and limited success. The only really effective treatment at this point is Botox injections to try and shrink down the size of the muscle that becomes evident when clenching or chewing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom midface implants.  I am 28 years old. Before double jaw surgery, I was diagnosed with Class III malocclusion. I underwent a Lefort 1, BSSO of the mandible and genioplasty involving advancement and rotation. What I noticed after double jaw surgery was that the rest of my midface was ‘left behind’ by the procedure, and appeared sunken and unnatural. 

So the following year I got a zygomatic sandwich osteotomy for anterior projection of the cheeks which managed to make a huge difference and restored some balance. However the result still looked odd, mainly because the orbital region was left behind which made my eyes appear somewhat bulgy. So towards the end of last year I got orbital rim implants that extended out laterally to cover the bone to the outside corner of the eye. Again this made a big difference to my sunken under eye area, but it didn’t reduce the appearance of prominent eyes at all. I was confused for a while after this, but then I realized that perhaps the reason why the implants didn’t help the bulginess at all was because they were placed in front of the infraorbital bone. Visualizing it, I imagined that the implant needed to be placed on top of the orbital rim, pointing upward and forward rather than just forward. This thought came to me after thinking about the counter clockwise rotation that I received. I went on to think that maybe I should have got ‘counter clockwise rotation’ of the area around the orbital rims just like I did for the lower part of the midface. It wouldn’t be true counter-clockwise rotation of course, but the effects of the implant would mimic that in the sense of pulling the infraorbital margin upwards and forwards, rather than just providing more volume to the front of the upper midface. 

The other issue I noticed only after going through double jaw surgery and the orbital rim implants was that the ‘inner’ part of the upper midface still appeared recessed. By this I mean the position of the junction between the ‘flat’ part of the midface and the nose itself, stretching from the medial side of the eye, all the way down to the base of the nose. I did a bit of research on this and found out that the Lefort 2 osteotomy is equipped to mobilize the nose including the nasal bone and the frontal process of the maxilla in addition to the lower maxillary region. In other words, the junction I am referring to is the groove at which the frontal process of the maxilla sharply changes direction to form the top part of the nose. This ‘groove’ or ‘junction’ sits too far back into my face, giving a flat appearance to my midface, only the lower part of that groove was fixed with the Le fort 1. 

So there are two questions that I have about the issues I have discussed:

1) Whether an infraorbital implant can be custom made to give upward and forward projection from the infraorbital margin, and whether you think that this is a better option to fix the appearance of bulging eyes than just a standard orbital rim implant design

2 – Whether any sort of custom made implant can be placed around the area of the groove between the nose and the horizontal part of the midface, running all the way up the midface, to simulate the effect of a Lefort 2 osteotomy. I noticed in some of your posts that implants can be fashioned to replicate the movements of a Lefort 3 osteotomy, so if there are any ways to move the area mentioned forwards, I would be eager to go through with it with you.

Thanks so much for your time Dr. Eppley.

A: Thank you for your inquiry and detailed description of your facial surgery history and anatomic concerns.. In summary you have done a variety of procedures that have been chipping away at a total midface advancement. Custom midface implants can be designed just about anyway one wants based on the soft tissue stretch and tolerance of the tissues. Whether it is to raise up the infraorbital rim or fill in the paranasal-maxillary region, they can be so designed to do so. A 3D CT scan would show exactly the positive augmentative midface changes you have accomplished as well as the parts of the midface that have been left ‘behind’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Following research on Skull Contouring, I write to seek your advice on how to progress matters further with you, I currently live in the UK.

From my research I believe I have a degree of the common condition ‘sagittal crest deformity’ I would like to smooth out a bump located on the top of my head near the back, ideally via a small incision at the back of my head followed by bone burring.

I also observe a further bump which is very small, located close to the above, on the back of my head near the crown. I attach photos as I’m sure these will prove useful for your evaluation purposes. 

Your thoughts would be much appreciated, I look forward to hearing from you in due course.

A: Thank you for your skull contouring inquiry and sending your pictures. You have correctly identified your skull deformity as that of a sagittal crest deformity. Its treatment would be as you described as a bone burring reduction through a small posterior scalp incision. The amount that the sagittal skull bony crest can be reduced would depend on the thickness of the sagittal crest bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in occipital migraine surgery. My story starts 20 years ago with a car crash taking the windshield out with my head and then a few years later I was at stop light and a drunk driver rear-ended my car.  My head rocked off steering wheel causing severe whiplash. For years I was treated for migraines with no relief. About 10 years ago was finally diagnosed properly with occipital neuralgia. I’ve had 4 nerve blocks over the past few years with some relief except this last one went haywire.  My doctor said that the occipital nerve is just angry from injections but it too is very painful. The pain starts in the center o my neck base up to my right ear. I can show you from the outside exactly where that nerve is. It throbs in the same place during every flare. When its not flaring, its sore and tender. It hurts me at least 3 times a week. My doctor thinks it’s a good idea and supports a visit to see you.. She also said she would be happy to send my info to you if needed. My latest MRI was last fall. Trust me I’m a veteran with this condition and I’m over it. That’s why I’m begging for help from you

A: Thank you for detailing your migraine headache history and symptoms. Just based on your description I could not imagine a patient with more specific symptoms that would be most likely to get some relief with occipital migraine surgery. (nerve decompression) The fact that you can precisely pinpoint the exact location of the pain, that it is consistently reproducible and gets some relief with injection therapy speaks favorably for a positive response to migraine surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower face reshaping surgery. My lower face is very heavy. My biggest concern is my double chin and round lower cheeks which look like a chipmunk. I am Interested in chin and/or jawline liposuction and maybe a small chin implant. Also, I have a very boulbous nose tip. I dislike how my nose looks from the front view but am not interested in a full rhinoplasty. Maybe just a nasal tip plasty or nostril reduction will do. I am looking for treatment suggestions to improve profile and a subtle refine nose tip. I have included some pictures for your review and suggestions.

A: Thank you for sending your pictures for consideration for lower face reshaping. In addressing your lower facial concerns, I can see the benefits of defatting it with a combination of submental liposuction, buccal lipectomies and  perioral liposuction. This would be combined with increasing chin projection slightly through a vertical lengthening chin implant and a tip defining rhinoplasty. This combined approach will provide improvements in the shape of your lower face through narrowing and lengthening it as well as concurrently addressing the wide nasal tip concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to shorten the midface? Is there a surgery for midface shortening?  If so how much can be done? I don’t have a gummy smile, just a long distance from my eyes to my mouth. I plan on getting jaw advancement to lengthen my lower face, but I still think the midface would be out of proportion. Would a rhinoplasty and lip lift help? I don’t have any pictures, but I hope you may give me a general idea as a plastic surgeon. I understand I would still have to see one in person eventually. 

A: There is a midface shortening surgery that is based on vertically shortening the length of the maxilla. This is known as a Lefort 1 impaction procedure that is used in the gummy smile patient to treat vertical maxillary excess. This does not appear to apply to you. Other than this skeletally based procedure, only a camouflage approach may provide some benefit. Procedures such as a rhinoplasty and a lip lift can be of some benefit to create a midface shortening effect depending on the shape of the nose and the length of the pper lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am perusing further information about your silicone Pectus Excavatum implant surgery. My questions are about the cost of the procedure and other normal questions such as recovery time and the amount of pain those who have the procedure are under. Does the implant go under or above the muscle? Also, how many times have you performed the procedure?

A: Thank you for your pectus excavatum implant inquiry. The cost of the surgery is highly influenced by how the implant is made, whether it is done by a 3D computer design method or a silicone elastomer moulage technique. My assistant will pass along the cost of either approach to the surgery to you next week. Regardless of how the implant is designed, most of it is placed over the depressed sternum where there is no muscle. If any portion of the implant goes beyond the sternal edges it will go on top of the pectoralis major muscle. It can not go under the muscle due to the tight attachment of the pectorals major muscle to the edges of the sternum. This is not a procedure that is associated with much pain. Recovery time is determined by what activity you are trying to recover to do. Most strenuous activities that involve a lot of arm motion and strain should be deferred until 3 to 4 weeks after the procedure to avoid the development of a serums. (fluid collection).

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reconstruction. I had a motorcycle accident caused a de-gloving injury and tore my skin down off my forehead in a triangular fashion starting at the widows peak tearing down over right eye stopping at mid eyebrow  and on left side across and down ending next outer edge of left eye between outer edge of eyebrow and left eye itself.

A few things… my left eye you see the eyebrow is high and it creeps up higher as day goes on at night it becomes quite pronounced. This eyebrow creep was initially mediated with botox injections after orbital fracture surgery. Ten years ago a plastic surgeon took a piece of my skull over my left eye about 3 inches behind hairline to rebuild area fractured under left eye. This area of skull is now an indentation  about 3×2 inches oval shape concaveing about a 1/4 inch depth that is trouble some to me and keeps me from cutting hair as I would like (short) has odd sensations to feel and is deformed enough to bring attention same as eyebrow .

I have a similar situation of strange sensation’s over my left eye it is hypersensitive. My brow as a result of the emerge nay nature of accident was sewed together in flight for life travel and although curative left me with funny brow lines that are mess matched and the creeping eyebrow. 

A separate issue came about from skin cancer surgery on  left side of nose and has left my face dropping pulled or distorted on the lower left. See the nasolabal fold is not equivalent nor within normal range of normal nonequivalent range. It caused a pulling too from under left eye and in conjunction with orbital surgery left the field under left eye different then right eye.

I further think I should look at my nose it was broken 2 x and my left nostril runs at far less capicity then right. I always have to clear my throat and feel dripping of mucus especially when sleeping down my throat.

I was hoping for some help with breathing and stopping the sinus draining down my throat as well as more balanced face and correction of indentation and brow.

A: Thank you for sending your picture and providing the detailed description of your facial concerns. To ensure I have an accurate listing of your concerns and their potential facial reconstruction treatments, I enumerate the following;

1) Skull Defect From Bone Graft Harvest Site – This is a partial thickness skull defect from the removal of the outer table of the skull from the bone graft harvest. This can be completely built out/leveled by the application of hydroxyapatite cement.

2) Left Eyebrow Elevation/Asymmetry – This is the result of the transection of the frontal branch of the facial nerve from the oblique laceration that went down to the outside of the eye. This cut directly across the path of the nerve that is responsible for forehead movement. This has resulted in permanent paralysis of that side of your forehead. Over time the paralyzed eyebrow continues to retract upward due to lack of any downward muscle pull. While motor nerve function can never be restored to the paralyzed eyebrow, it may be possible to realign the scar line so that the eyebrow is brought down lower and the horizontal wrinkle lines match up better.

3) Left Eyebrow Dysesthesia/Sensations – Like the frontal branch of the facial nerve, the large sensory supraorbital nerve coming out of the brow bone has been similarly cut. While the nerve ends are long past being able to be repairs, the trunk of the nerve where it comes out of the bone could be released from the scar and perhaps this may improve the strange sensations.

4) Left Lower Eyelid Contracture – The left side of the nose was reconstructed with a rotational nasolabial flap. This is a concept of ‘robbing Peter to pay Paul’. As a result there is a relative tissue deficiency between the lower eyelid and the nasolabial fold, making it tighter than the other side. An effective treatment strategy would be fat injections to try and loosen up the tissues.

5) Nasal Airway Obstruction – I can’t obviously know what the inside of your nose looks like and this will require a CT scan for evaluation/confirmation of internal nasal anatomic obstruction. Septal straightening and inferior turbinate reduction surgery may be appropriate

These are my initial thoughts,

Dr. Eppley

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding custom wrap around jaw implant to improve asymmetry and enhance jawline.

I have fractured right sub condylar part of the mandible 6 months ago. It has healed nicely although I believe I lost some bone which is causing slight assymetry compared to the left part of the jaw (loss of hollow cheeks and slightly ”fatter” look on the affected jaw). While the assymetry might not be huge, I would like to have it fixed. 

I’m wondering if custom jaw implant could be better option that orthognathic surgery, as I would like to wider my jaw and lengthen the chin in the process. Could the perfect symmetry be achieved with jaw implants only?

A: In looking at your x-ray as well as knowing the natural history of healing subcondylar mandibular fractures, you have not ‘lost bone’ per se. Rather, as is common with these type jaw fractures, you have lost vertical height (top of condyle to jaw angle) as it has healed. (partial condylar collapse) In short, the vertical height of the mandibular ramus is now shorter. This is the current source of your jaw asymmetry.

That could be treated by either a standard small vertical lengthening jaw angle implant or a custom made one.

Certainly any form of jaw implant would be far more effective to simultaneously lengthen the chin and widen the jaw than orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery. I have deformities in my skull that I would like to change. I don’t know if my skull is changing still or what caused my skull to change into this shape. But I have my brow bone sticking out in the front, the right side of my head to stick out more than my left (which if you see my right eye its more into my skull than my left eye), and I have my skull is not flat on top. I have not been to the doctor about these issues yet. Seeing what my current options are to fix this and if you have any insight on my skull defamation.

A: I can not speak to why your skull has developed this way, I can only address how you would treat it. Your strong brow bones can be reduced through an osteoplastic brow bone setback procedure. The right temporal protrusion can be reduced by a combination of total muscle and subtotal bone reduction. The top of your head is the biggest challenge, as some height reduction can be done, you can never get it close to being flat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 year old female who underwent facial slimming surgery. It’s a long, complicated story but a few years ago, I went to South Korea to just get a sliding genioplasty because I’ve always had a weak chin and I was told they were the best in the world for that sort of thing so I spent all my savings to fly there and get it done. They did that successfully. However, I am not sure if something got lost in translation before surgery or what happened, but without my permission, they also lowered my cheekbones (they actually shaved and broke the bones and I now have screws in my face) and cut a part of my jawbone. Now I have sagging skin, weak cheekbones, and jowls due to this. This whole thing has been a nightmare and I desperately need help. I am not sure what surgeries I need. I miss my high cheekbones and I hate the sagging skin and jowls. I would do anything to fix this mistake as it’s been really hard on me. Thanks

A: What you had was the classic Asian surgery of facial slimming including cheekbone reduction, jaw angle reduction (amputation) and a sliding genioplasty. This is a very common surgery in many Asian patients to try and change a wide face into a more narrow one. While it can be appropriate for some Caucasian patients, it is far less commonly needed. I suspect nothing got lost in translation. That was just what they were going to do and your aesthetic desires were secondary or irrelevant.

That being said your facial issues are loss of soft tissue support of the cheeks and jaw angles. Re-establishing the jaw angles is fairly straightforward using vertical lengthening jw angle implants. Whether they would be standard or custom implants is matter of debate. For the cheeks it is a bit more of a complex decision. The cheekbones would be refractured and brought back out or cheek implants could be placed to create the augmentation and re-establish cheek support.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in adult skull reshaping surgery. I am 26 years old and just realized that I have a scaphocephaly. My head looks more or less normal from front view but extremely terrible, big and large from the side. My parents refused the surgery when I was a baby. I have always been complemented by this malformation. 

Today I want to know if the surgery is still possible? I thank you in advance for your reply.

A: Congenital craniosynostoses, like sagittal or scaphocephaly, is commonly treated as an infant where the bone is removed and rehabbed. This works well as an infant because the bone is very thin, easily removed and can be reshaping after surgery by the growing brain. That window of opportunity for that type of surgery passes with in the first two years or so life. As an adult scaphocephalic skull shapes are treated by sagittal ridge reduction and a custom implant to build up the deficient parasagittal areas. I would need to see some pictures of your head to determine if this might be an effective skull reshaping approach for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking orbital dystopia correction. Having seen some of your earlier work regarding orbital surgeries I think you are the best one to know what my options are. I am a male, 25 years old. For as long as I can remember I’ve really been disliking my orbital asymmetry. I don’t know if it’s become worse with age/time but my left “bigger” eye is constantly focusing lower down than the right “smaller” eye. The pupils are never aligned. This phenomenon was a tricky one for me for many years, because it almost mimicks “ptosis” because the lid and the right eyebrow sag down on the same side. But as the pupillary distance is vertically different (1-2mm) that must mean that my eyes are set differently as well. I am so depressed by this discovery that I don’t know how to approach people or even look people in the eyes without wanting to look the other way. The right eye also seem to have a slight slant. When I put my chin to my chest, eyes straight up in the ceiling, the right eye always goes higher up than the left. 

It seems my right eye is set further back, thus looking smaller and also makes the lid sag more. But could this be enophthalmos (sunken globe)? Notice the right eye in a few pictures with my head tilted back.

Here in my country, I get zero help from opthalmologists or other specialists, despite having done a lot of research and presented to them. Either they don’t understand the underlying problem or they think I shouldn’t worry or exaggerate it. So my chances of help over here are pretty much limited. So that is why I am contacting you. 

A: Thank you for your detailed inquiry and sending your pictures. As you may or may not recall you have previously submitted and inquiry with pictures (which I still have) so I am familiar with your case. The best way to confirm and quantify your orbital dystopia is with a 3D CT scan. It will no doubt confirm that the right orbit is lower than the left. It will also establish by what amount. Beyond the diagnosis the greatest value of the 3D CT scan would be when planning for surgery in the creation of how thick an orbital floor implant would need to be. But an orbital floor implant alone will be inadequate. It has to be combined with a right browlift and upper eyelid ptosis correction. Otherwise all you do is bury the elevated eye up under the eyelid.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull reshaping procedure which is likely to be an extensive procedure. My head is very angled and flat and would likely require implants to achieve the desired shape. Some questions I have regarding the procedure include: 

As I currently live in Australia, what would be the required or recommended duration for me to stay close to the hospital post surgery? 

What type of risks are associated post surgery as I age? Eg would there be any limitations on physical activity, will there be any need for adjustments? 

These are the main questions that pop into my head for now (pun intended) regarding the surgery. Appreciate any feedback.

A: Since I don’t know what your particular skull reshaping needs and procedures may be, I can only make general comments to your questions.

1) There is no reason to ‘stay close to a hospital’ during or after the surgery. This is aesthetic skull surgery, not neurosurgery. There are no neurologic risks from undergoing the surgery.

2) There are no limitations on physical activity after the surgery.

3) I am not aware of any age-related risks from skull reshaping surgery.

I hope this is helpful,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in the mouth widening surgery known as lateral commisuroplasty and I’d also like to pursue a lower lip reduction surgery. 

As you can see on the photo below, my lips are pretty narrow and so my mouth is barely any wider than my nose. If I were to undergo a lateral commisuroplasty and a lower lip reduction procedure could I achieve a mouth appearance very similar to these? How much would the two lip procedures cost? 

Also, I looked up photos of jawline augmentation on Google Images and one of them was this Did this patient have a lateral commisuroplasty procedure? I notice that his lips are wider in the after image as there are also some noticeable scars on his mouth corners.

A: It is possible to do a lower lip reduction and lateral commissuroplasties (mouth widening surgery) at the same time.  In looking at your pictures and those of your ideal goals, that is not an achievable mouth widening goal.Realistically you could probably achieve about 1/2 to 3/4 of where you are now compared to ideal mouth width. In the jawline picture that is not my patient so I can not say what procedures he had done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am suffering from a too narrow/small head. I  hated my hairstyle every day, physical complexes, missing self-confidence. In addition to the external phenomena (daily struggle with the hair, the hairdresser, always looking in the mirror without anyone noticing), it is more the internal psychological phenomena, which destroy my self-confidence more and more (no self-assured occurrence, doubt, fear in meeting new people, afraid to present things at work or speak up). I am now at an age where I would like to change this before it will further destroy my self-confidence. Please could you take a look at my pictures and let me know if there are treatment options? 

A: The narrow head, signified by a a straight or convex profile above the ears, is a deficiency of the posterior temporal region primarily. This can be very effectively treated by  the placement of submuscular temporal implants. These would need to be custom made based on the dimensions of your temporal region and the extent of coverage/augmentation that is needed. The typical thickness would be around 1 cm above the ear region. These implants are placed through incisions on the back of the ears.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How to improve my undereyes? Can a chin augmentation be done that doesn’t simply just push the bottom tip of the chin forward ?(but fills in below the lower lip as well)

A:In regards to your chin augmentation question, the depth of the labiomental fold (under the lower lip) can never be changed by any form of chin augmentation and it will always end up a little deeper with any form of increased chin projection., That is because the labiodental fold represents the attachment of the mentalist muscle above the chin bone. The attachment of the muscle can not be changed or removed for the obvious functional reason. That being said it can be treated at the same time as a chin augmentation by either fat injections  (externally) or a dermal-fat graft. (internally) The latter is more effective at reducing the labiomental fold than the former.

Your lower eyelids show classic pseudo fat herniation due to recession of the infraorbital rims. This can be improved by a lower blepharoplasty that takes the bulging fat and repositions it over the bony infraorbital rim bone to create a smoother lower eyelid contour into the cheek.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Would a tummy tuck work on me. I have a protruding abdomen. reason I have contacted you is because of an article that you wrote about the fat in the upper abdomen and being realistic about what a tummy tuck can do. I would really like to avoid the dangers and the scars of this type of operation. So please find attached my photos and I look forward to your advice on what sort of procedure would be best for me. 
I am 5 feet 2. And weigh 156pounds. I have had a c section twenty years ago. And my appendix removed. 

A: Thank you for sending all of your pictures. While you definitely need a tummy tuck, the question is how you prefer to ‘stage’ it. As you have read in my articles the upper abdominal fat is a challenge to ideally manage at the time of a tummy tuck. If you aggressively liposuction fat in the upper abdomen at the time of a tummy tuck, there are increased risks for causing wound healing problems of the tummy tuck incision. To prevent this potentially devastating complication, it is safer to do some upper abdominal liposuction at the time of a tummy tuck conservatively knowing that a complete flattening of the upper abdominal area will not result. This is why I tell many tummy tuck patients that it may require a second procedure six months after the tummy tuck to come back and liposuction the rest of the upper abdomen to reduce the upper abdominal bulge. The other approach is to do aggressive liposuction of the full abdomen, flanks and waistline first and then come back six months later to so the ‘completion’ tummy tuck which now will not require liposuction. Ss you can see, either approach to your abdominal contouring will involve two stages…it just depends how one wants to approach it. The second approach (liposuction first, tummy tuck second stage) is how most BBL (buttock augmentation by fat injection) procedures are done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty revision. I have previously had a sliding genioplasty with 5mm advancement and liposuction to the neck. I still have fullness under the chin that I feel could be improved through further chin or a jaw advancement to enhance my side profile and align the chin with the bottom lip. I feel an additional 5mm would suffice.

The first option I am considering is a sliding genioplasty revision that would provide the desired 5mm projection for better alignment. This would also assist by making the muscles and skin more taut to decrease the fullness in the neck region. Is there any structural risks advancing another 5mm in performing another genioplasty. Is my chin bone thick enough to support another 5mm?

The second option; braces to the lower teeth to shift the teeth back 5mm and then performing lower jaw surgery and advancing the jaw by 5mm.

The third option; platysma plication to tighten the muscles and/or shaving the digastric muscles, submandibular glands or lifting the glands up via suture support.

I have attached a photo highlighting the area of concern and an x-ray; you will see my teeth are already fairly aligned and bite is fairly good.

I have also had a CT scan which shows no chin fat as a concern and the submandibular glands are not abnormally large.

I would greatly appreciate your opinion as to the most suitable surgical option to move forward with. Also, based on aesthetics alone; is a lower jaw advancement compared to a genioplasty more pleasing to the eye? Do they bring forward the same muscles?

I look forward to your opinion and greatly appreciate your thoughts and time.

A: Thank your for sending your facial pictures and images. In answer to your questions:

1) You have enough bone to allow for another 5mm increase and 2-3 mms vertically down for your sliding genioplasty revision. Your chin still remains dimensionally short, 5mms was an inadequate movement from an aesthetic standpoint.

2) Your submental fullness can be further improved by direct supraplatysmal defatting (liposuction always leaves behind more than one thinks), direct subplatysmal defatting, platysmal muscle plication and partial resection of the anterior bellies of the digastric muscles. Collectively this is known as a submentoplasty procedure. In my experience the common use of just neck liposuction is often inadequate for many men as it only addresses what lies above the muscle which is often just half or less of the anatomic reason the submental fullness exists. The thicker tissues of men usually require a more aggressive approach.

3) Your outline of what can be achieved by a more thorough neck contouring approach is not realistic. The back half of  your drawing is on the jawline and not on the neck. I have provided a more accurate representation of the actual zone of submental/neck improvement.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgical tattoo removal by excision. I was asked to provide a picture of the tattoo I wish to have excised. (I’m having to go this route since laser will take too long before my new job will be starting).  I do realize that there will be a scar created in this process and I’m absolutely fine with that.  As you can see, the tattoo is on my hand, and the skin there is not taunt as it is on many others, so I’m hoping that will work out in my favor.
 
Thank you so much for looking into this and I look forward to talking with you about this tattoo removal procedure.

A: The surgical tattoo removal approach to your dorsal hand tattoo would not be excision and linear closure. It is simply too big to be done that way, there is not that much loose skin on the back of the hand…or just about anywhere on the body for that matter. For a single-stage surgical approach the tattoo could be excised completely and skin grafted. Skin grafts on the back of the hand take and heal very well. It will create a patch-like appearance since there will always be some color mismatch between the skin color on the back of the hand and the donor site. (usually the outer thigh) But as long as the ‘patch’ is better subjectively than the tattoo then this would be a favorable trade-off.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in an upper lip lift. I have plenty of upper and bottom lip, however, my upper lip seems thin. My concern is not just aesthetic. My upper lip sags right along my teeth, which makes smiling not as automatic for me as for some people (if that makes any sense). For my teeth to show in a smile, my smile has to be genuine and pronounced and extend to the muscles on the upper half of my face. I’m actually a pretty content/happy person, but people seem to think I’m not. To complicate matters, I have a medium olive skin tone and scar easily. Is it possible for me to have this surgery without scarring?

A: Thank you for your inquiry. An upper lip lift will shorten the distance between the nose and upper lip and will have a more limited effect on showing more upper teeth. In some cases I perform a horizontal mucosal line at the smile line at the same time to create more of a tooth show effect. In my experience with patients with more significant skin pigments, I have not see the sub nasal lip scar from a lip lift to be an aesthetic problem. BUT all lip lifts create scar, there is no such outcome as no scarring. It is all about how well that scar will look.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have had a few questions occur to me about my upcoming zygomatic arch reduction surgery. 

First, lowering my zygomatic arch seems like I could be creating a weak spot that could fail under pressure. I live an active life and would hate to have it crushed in during a snowboard fall should the hardware fail. Do you feel this is an issue? You mentioned you couldn’t get to the zygomatic arch to grind it down. I’m not sure what this means other than get to it without leaving a scar. I think I might prefer a small scar than a weak point. From the original CT scan it appeared to my untrained eye as much more bone than the opposing side and possible to grind down.

Let me know your thoughts.

A: In answer to your zygomatic arch reduction questions:

1) In regards to the zygomatic arch, it is not being lowered. Rather it is being medialized, meaning moved inward not down. This is a very stable position when secured with plate and screws. I would have no concerns about how it would respond to a traumatic event later.

2) You can’t get to the zygomatic arch to burr it down because of the size of the incision needed for that exposure plus the risk of injury to the frontal branch of the facial nerve which crosses over its middle portion at the highest point of its arc.

3) Also burring down the zygomatic arch is not an option because the bone is too thin to do so. One would simply have nothing left when even burring it down a few millimeters.

4) To do zygomatic arch reduction (aka cheekbone reduction osteotomies) this is done through a combined intraoral and small external incision (1 cm) in the sideburn hair.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in having a custom jaw implant to have a wider, more symmetrical and defined jawline. 

I, however, don’t live in Indianapolis so am unsure as to the process of getting this done. Do I need to come to Indianapolis more than once? Or can I just send the CT scan that I have already done, have Skype consults and only come in once?

In terms of timing I have a tight schedule with uni. Ideally I would be hoping to get this done in January but am unsure if this is realistic with your schedule and time required for everything to be ready? How long does it take for the designing and the printing of the implants? When would your next availability for such surgery be?

If everything works out, what is the next step to move forwards with the implants?

A: I have many patients from all over the world who come in for custom jaw implants. Except for the surgery, all related matters can be handled by email, phone and Skype. You can get the 3D scan that is needed for implant design and fabrication where you live and I can order it for you.

It usually takes 3 to 4 weeks for the implant to be designed, fabricated and shipped for surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock augmentation by fat injections. I have attached pictures to see if I am a good candidate. I would like a nice round booty if you think it would be possible.

A: Thank you for making the effort in sending your pictures. You have several issues of relevance to your desire for buttock augmentation. The overall amount of fat that you have to harvest is adequate but marginal. The fat alone would produce a modest buttock augmentation result but certainly not a large result…or as you have desired a ‘nice round booty’. You simply don’t have enough fat to do it.

You also have a lot of extra and loose abdominal skin and you really need a tummy tuck and not just abdominal liposuction alone. Ideally the best approach in our situation is to do a combined BBL surgery with a tummy tuck and use the tissue removed from the tummy tuck as buttock implants. That tissue is placed into the buttock muscle and then fat is injected in the buttock tissues above the muscle. All together this will give you the best buttock augmentation result combined with major abdominal/waistline reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in learning more about laser lipo to attain a more defined jawline.

I have attached photos from a frontal, side angle and profile view for you to better assess if my request is a good approach to achieving my jawline goals. I am specifically trying to target the skin under my chin to prevent further aging that would require a more in depth surgery later down the road. 

A: Thank you for sending your pictures. I can clearly see your jawline concerns and what is masking your jawline is thicker soft tissues, not necessarily an underlying bone deficiency. I do not believe you can achieve your ideal goals by laser lipo jawline surgery but you can certainly obtain improvement. To do so you are going to have to do a maximum soft tissue reduction approach. This would include jawline and submental liposuction, buccal lipectomies, perioral lipsouction and masseter muscle reduction. This is the most soft tissue reduction you can do around the lower facial skeletal structures and is what I call a facial derounding technique.

In addition I would not get infatuated with laser liposuction. It sounds like it is better than traditional liposuction but in my experience it offers no significant improvement or recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In the past you have spoken about the “chin wing” surgery procedure and conveyed you are not a big fan of it

On some surgery forums however, it has come out in the wash that the procedure being described by European surgeons to treat problems of jaw width is not the “chin wing” as is traditionally described in the literature but rather would be more aptly described as a “side wing” where instead of making a cut and sliding forward, the focus is on widening the mandible and then fixing in place I believe.

Have you heard of anything like this and what is your opinion on such an approach? Its my understanding the augmentation of such an approach is very limited at what can be achieved in one operation, but can also be enhanced by widening the chin at the same time.

A: My opinion about any bone procedure that tries to augment the entire jawline is that it conceptually flawed. It is simply not possible to move the jawline around, regardless of the dimensions, to have a profound jawline augmentation effect. It simply will not be effective for most patients. I certainly understand the appeal of using our own bone. But when the aesthetic result can not be achieved, and bony stepoffs result, the use of one’s own bone becomes an irrelevant advantage. When one compares what any bone procedure can do versus a custom jawline implant…there is no comparison.

But it also depends now what type of jawline augmentation one wants to achieve. For some limited improvement, like chin advancement and widening, such bone procedures are useful. Just not for an entire jawline effect.

The conclusion is I am a big fan of what works and not a big fan of procedures that don’t.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a big masculine jawline implant, plain and simple. It’s bothered me for years. It’s a little concerning that there isn’t a lot of before and after examples of people who have had with this procedure. I’ve been looking for over a year and i came across your site. You have far more examples then most doctors.

A: Thank you for sending your pictures. The difference between your jawline and that of your classic examples is you have a high jaw angle, short chin and lack of angularity at either location. You are correct in that only a custom designed masculine jawline implant can make those desired changes. It is also relevant to point out that every example you have shown has a very thin face with little fat. (which is one reason they have jawline and facial angularity) Conversely your face has thicker tissues. So while you can achieve a major jawline improvement it would not be realistic to assume your new jawline will look exactly like that of your examples. But there is no question that you can achieve a much stronger lower facial appearance with a masculine jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there any possibility that a facial implant could become infected years after it’s put in? I’m guessing that if one were to have any kind of further surgery on the mouth (e.g., dental implants) then there would be a risk, but in general is there an infection window? The idea of wondering each day whether an infection could suddenly appear makes me uneasy. Especially as financial positions change down the line.

A: Any time you have a facial implant there is always a lifelong risk of creating an infection from one historic source….dental treatments. If the dentist is unaware that an implant may be below the tissues the injection of local anesthetic could inadvertently enter the implant capsule and innoculate the implant with bacteria. This is very rare but there have been a few documented cases of this occurrence. This risk is actually higher with cheek implants than any chin or jaw implant because where the needle would be placed to create local anesthesia is closer to where the implant resides. (maxillary vestibular infiltration) It is a consideration in a jawline implant but it is so exceedingly rare I am unaware of a single reported case.

Today’s aesthetic world has also created an additional risk for needle penetration into the implant capsule…injectable filler injections. This is more relevant in cheek and infraorbital rim implants because of the thinner tissue cover over them and being a frequent location for injectable soft tissue augmentation.

Dr. Barry Eppley

Indianapolis, Indiana