Your Questions

Q: Dr. Eppley, I need your opinion for my very specific facial implant selection needs describe d below. I also posted photos of my face (front – side view & oblique) in order for you to understand better my situation. The 3 photos are real, as I am (the before) and the modified photos are fake (modified in Photoshop) and show the desirable effects, what exactly I want to achieve after the aesthetic surgery.

As you can see, I want to achieve a more masculine facial structure, as well as a more prominent jaw line and reducing the roundness appearance of my face. I’ve decided to go on with 3D facial plastic surgery, in addition with buccal fat pad removal (I ‘m not interesting in typical, non-surgical methods). I know most of the basics and I am looking for the right doctor in order to proceed. But I have some questions to ask first.

1) Which chin implant would be better according to my needs, in order to achieve the effects in the modified photos? Conform™ Extended Anatomical Chin Implant, Extended Anatomical Chin Implant, Terino Extended Anatomical™ Chin Implant, Vertical Lengthening Chin, Mittelman Pre Jowl Chin™, Mittelman Pre Jowl®, Glasgold Wafer, or Terino Square Chin (All styles) ?

Chin Augmentation Goals: stronger – masculine chin, a little front, side and vertical widening, as photos show.

2) Again, which jaw angle implant would be better, the Conform™ Mandibular Angle Implant, the Widening/Vertical Mandibular Angle Implant, the Lateral Mandibular Angle™, or the Posterior Mandibular Angle™ ?

Jaw Augmentation Goals: The main point here is to enhance the vertical facial structure of the face and secondly the angular shape to be more prominent BUT without enhancing the roundness of the face.

3) In addition to these augmentations, do I need cheek augmentation to achieve the desirable effects? Or the buccal fat pad removal is enough according to my case? If I need, which of the three options would suit better in my case? Malar, Submalar, or the Combined Shell?

The goal here is to achieve more tight and high cheekbone effect and with no fill and volume, just like men models.

4) Would you suggest to go for temple augmentation too, in order to achieve a boarder/wider forehead and a more masculine effect? Or not?

Thanks! 

A: In answer to your facial implant selection questions:

1) I can only provide specific implant recommendations to patients that I have consulted on and I am performing the procedure. It is ill-informed to do so otherwise.

2) Buccal fat removal can never achieve your imaged effects and always has to be combined with cheek augmentation to come close to that midfacial effect.

3) Augmenting the facial skeleton will only make the temporal hollows look more pronounced not less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read your article online regarding Fractora vs a facelift and you mentioned that you would review pictures. See below. Would I benefit  from Fractora or perhaps an injectable filler? Not sure which way to go. Thank you for your time.

A: In answer to your facial aging treatment questions, this is a classic debate between fillers, fractional laser resurfacing (Fracture) or some type of lower facelift. It is important to understand that in this spectrum of facial aging treatment options they have very different effects and are used for different facial aging concerns. Your facial aging needs are beyond what fillers or laser resurfacing can really improve much and they would be considered a poor financial investment. Your only good choice is to have a lower facelift procedure which is the only economically worthwhile approach. You may opt for laser resurfacing because it is not surgery but with the understanding that its benefits will be very limited and not the equivalent of a facelift.

In reality in your case, fractional laser resurfacing is a good complement to be done after a facelift. But it is certainly not a substitute or an equivalent treatment for your facial aging concerns..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a closed rhinoplasty correct some tip asymmetry. My questions are:

1. What will be my limitations post op? Can I play sports? Can I blow my nose? What happens if a ball or object hits my nose? Can I go swimming? Etc

2. Is there any possibility that the procedure would produce a more asymmetric nose tip? Or is it guaranteed that I will at least have more symmetry?

3. What will you actually be doing to my nose in order to achieve the more symmetric tip that I want?

4. How long will I have a cast over my nose?

5. What is your policy on revisions?

6. Will my nose have anything foreign in it ?

7. What are some potential complications or risks with a nose like mine?

8. What is your revision percentage for rhinoplasty?

9. About how many closed rhinoplasties have you performed? 

10. Will you only be doing work on the asymmetric side of my nose or do both sides of my nose need work in order to achieve what I want?

11. I attached more realistic before and after photos where I do not use a mirror, but instead just used a morphing app to reduce the hump on the left side of my nose. How realistic is it that you can achieve this result for me?

Thanks in advance!

A: In answer to your closed rhinoplasty questions:

1. Other than some compressive tapes on your nose for the first week after surgery, there are no physical restrictions…other than common sense ones like no contact sports for the first few months after the procedure.
2. By removing some of the excessive lower alar cartilage on the fuller side, it would one hard to imagine that the surgical result would the worse than before. The very likely outcome is that the asymmetry would indeed be less.
3. A cephalic trim of the left lower alert cartilage would be done.
4. The tapes would stay in place for 5 to 7 days after surgery.
5. The revision policy is written and is one in which you are already familiar since you have seen and signed that policy paper from your recent surgery.
6. There will be no foreign materials used in your nose other than resorbable sutures.
7. The risks of this surgery are exclusively aesthetic…how well does it meet your aesthetic nose reshaping goals.
8. The usual stated revision rate for rhinoplasty is between 10% to 15% on a national basis for primary (first time) rhinoplasty.  But that number is an average and does not take into account the type or complexity of the rhinoplasty being performed. Your proposed rhinoplasty would be considered ‘not complex’ and in theory should have a lower risk iof revision. But that would depend on the ‘perfectionist’ nature of the patient as that is what drives most revisional facial procedures.
9. I have performed many closed and open rhinoplasties.
10. Based on our own imaging, it is presumed that only reduction of the larger side is needed.  But that depends on your nasal tip reshaping goals.
11. Your imaged results appears realistic and is an achievable goal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in secondary rib graft rhinoplasty. I had silicone rhinoplasty done seven years ago. (they used silicone for the bridge and septal cartilage for the tip).Although I am very happy with it aesthetically, I also started getting autoimmune problems shortly afterwards and now have full-blown Lupus. While the link between silicone and Lupus isn’t firmly stablished, I don’t want to take any chances and would like to swap out the silicone for rib. Is there any way I could do this via closed rhinoplasty?

A: You are correct in that there is no established connection between solid silicone implants and autoimmune diseases currently. But I can certainly understand what you would want to replace your silicone nasal implant. While I have no idea of your implant’s size and shape, it can certainly be replaced with a rib graft. Some general comments about rib graft rhinoplasty in your case would include the following. It may be possible to use a closed approach for the replacement as the implant has an established capsule/pocket. Whether the rib graft should be inserted as a solid piece or in a diced fashion would depend the shape of the harvested rib and its ability to be inserted through a closed approach. It would be important to realize that any form of a rib graft may not have the completely smooth and perfect shape as that of a preformed nasal implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am seeking nasolabial fold correction. I wanted to see if you can help me. I have atrociously bad nasolabial folds by my mouth. I am young so I don’t know why, maybe weight loss. I wanted to ask your expert opinion. Do you think I have midface deficiency causing this or is it just that my cheeks have sagged a little bit? I need to know if I should do jaw surgery to correct an upper jaw deficiency or just have a facelifting skin procedure . I appreciating your opinion. Here my pictures.

A:Thank you for your inquiry and sending your pictures, Nasolabial folds remain a difficult challenge to treat on any permanent basis. I see no evidence in your face of a midface deficiency nor would upper jaw surgery ever be an effective treatment for nasolabial folds. They are not typically perceived to be a bone-based mid facial problem. They are a soft tissue problem not caused by a bone deficiency. Conversely a facelift of any form never effectively treats nasolabial folds in any sustained fashion. The best approach for nasolabial folds correction remains release with injectable therapy whether that be synthetic filler, fat or even implants.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding cheekbone reduction. I know that cheekbone reduction is often performed in patients seeking to reduce the width of the face. However my issue is slightly different. Essentially I have low set cheekbones that project, both forward and laterally. To me this gives a very feminine look, and the reason behind it is that the zygomatic prominence is too low down on the face, causing the ‘bulge’ of the cheek to be too low. So I was wondering whether it would be possible to reduce the projection of the cheek in not only both the forward and lateral directions but also in the vertical dimension. My thoughts are that we would flatten down the projecting part of the cheek and then remove the bone forming the inferior border of the zygoma. Will we be able to achieve these objectives? If it proves to be impossible what is the closest we can come to achieving them?

A concern I have is that the soft tissue may not react well to reducing the size of the bone. I am worried that reducing the bone would just leave hanging soft tissue. Are my concerns on this matter valid? If so, can we do anything to help such as a midface lift to reposition the soft tissue against the new bone contours? 

A: The type of cheekbone reduction you have described can be done and is known as a zygomatic-maxillary corner ostectomy. That would address the bony ‘deformity’ that you have astutely ascertained. The concern about soft tissue sag is not without its merits although the superior zygomatic bone structure remains intact. To proactively address this potential concern one would do a soft tissue bone suspension of the cheek tissues at the time of the ostectomies.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for information on eye asymmetry surgery. I am interested in addressing my eye asymmetry as well as that of my face. I do not have any medical problems related to it as far as I know, but it is something that has caused me a lot of distress in my daily life and I worry it will worsen with time. One side of my face is more defined and lifted, including the eye, and other side of the face also looks more “pushed in” while viewed at 3/4 angle. I have attached my pictures for your review. I am interested in pursuing cosmetic surgery to fix these issues, and was wondering if your facility provided procedures that can do so. Thank you for your time and help, and I look forward to your response.

A: What you have is a vertical orbital dystopia that is part of an overall facial asymmetry. The eye area is always the most noticeable since that is what you ‘see’ the most. This asymmetry will not worsen over time since this is part of your natural facial development and is stable. The correction of such orbital dystopia (eye asymmetry surgery) is done through the placement of an orbital floor implant to raise the eye up. The eyelid will also need upward adjustment at the outer corner. A small cheek implant will also help to bring out that face ion that side next to the eye.

Ideally a 3D CT scan would show the degree of orbitofacial skeletal asymmetry and can be used to design the orbital floor implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in arm scar revision. I have several self-inflicted arm scars from several years ago. The three arms scars are 2 inches, 1.5 inches and the smallest at one inch. I have some general questions about the procedure:

1.Is it possible for my arm scars to be improved?

2. Do you suggest any alternate solution? 

3. How much would this cost me given that there are only three marks?

4. If this is surgery, how many days do I need to under your care? is it one time or do I need to come few times a year after surgery?

5. What potential side effects can occur?

A: Thank you for sending pictures of your arm scars. In answer to your arm scar revision questions:

1) The only benefit of scar revision would be if you think that the scars being narrowed would be of benefit. It is not possible to have the scars completely removed. There will always be scars, just more narrow with hopefully no white color.

2) There are no alternative solutions other than to cut them out and restore. Since they were original skin lacerations that were allowed to heal secondarily, the scar goes all the way through the thickness of the skin.

3) My assistant Camille will pass along the cost of the scar revision procedure to you tomorrow.

4) This is an office procedure done under local anesthesia. There is no aftercare needed and all sutures are placed under the skin and are dissolvable.

5) I would think that whatever scar improvement is possible with this type of scar revision, it would be seen after just one scar revision.

6) I see no side effects other than how much scar improvement is obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering arm lift surgery to remove extra arm skin and was referred to you to possibly do arm implants. (bicep and tricep implants) My question is can the implants replace the surgery and will that stretch out the excess skin in my arm so it no longer hangs. I am 60 years old and in good health and shape. Thank you.

A:Thank you for sending your pictures. Your concept of adding volume to the arm muscles to fill out loose skin is not completely unfounded. But the success of arm ‘voluminization’ depends on how much loose arm skin is present. What your pictures show are arms like look like someone who has lost a lot of weight. The back of the arm shows a classic bat wing deformity with a lot of loose hanging skin.

A bicep implant would fill out some of the overlying upper arm skin which is always less than that on the back of the arm. But a triceps implant would provide no benefit to the larger amount of hanging posterior arm skin. An armlift is really the only way to get rid of the posterior arm hanging skin. It is possible to combine an arm lift with arm implants if desired as there is convenient surgical access due to the arm lift incision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, My son, under the instruction of a general practitioner, was not given the green light for a helmet to treat plagiocephaly. We were told he would just grow out of it. He never did. One side of his forehead is more prominent than the other. It’s too late now as he is 4 years old. This raised my concerns, and after much research have come to find the rise of children and young adults effected by an uneven forehead due to the back to sleep programs of the 90’s.

There are hundred of parents that share the same concerns and numerous young adults seeking treatment of a lopsided forehead. My concern is that there are not enough surgeons worldwide with knowledge of correction techniques, such as custom made implants to even out this problem.

Please, if you have some sort of voice in the medical fields with other surgical professionals, could please bring light to these techniques. More training worldwide is needed. You are pretty much, the only surgeon that has any insight into this that I have come across. No one has ever heard of plagio forehead implants or treatment.

There needs to be much more research into this issue. Maybe you can train or help spread more awareness of how to surgically treat adults with plagiocephaly. Because, I guarantee ,now and in the future, it will help so many people.

I just Google about adults with plagiocephaly and many of them has felt suicidal, suffered depression or anxiety. This breaks my heart so much. Is there anything I can do to help spread awareness in the surgical community, please direct me how to go about it. Any information would be beyond welcome.

A: Thank you for your email. I certainly see and treat many patents with different forms of frontal and occipital plagiocephaly. I do find that the use of custom implants in teenagers and adults provides an effective improvement with a low risk of complications and aesthetic tradeoffs. Fortunately the internet provides the best forum for passing along this information as I try to do in my many blogs on this topic. I feel confident that what I do today, in time, will become well known and a more widely used surgical therapy for it. In surgery the adoption of newer surgical technique is often met with skepticism but successful outcomes eventually lead to it becoming an accepted and contemporary surgical approach.

Dr. Barry Eppley
Indianapolis, Indiana 

Dr. Eppley, I am considering custom infraorbital-malar implants. Currently I have orbital rim implants that are of silicone material but they are not fixated with screws and are an off shell product. I think it gives a good improvement of my flatness under my eyes, but they are a bit uneven because of the different sides of my face as they are not completely symmetric. The right implant is actually perfect, but the left is kind of strange as it seems like it sits a bit lower and it has a lump that goes outward close to my nose, and there is a gap between the implant and the lump that creates a crease. Its almost like the implant are in two parts on this side.

I have a couple of questions to you regarding the custom infraorbital-malar implants that I was hoping you could answer.

1. Have you done a lot of these implant operations before? Are you very experienced in it?
2. As I have two sides of my face that are not completely symmetric, would you custom make the implant to the different sides to try to achieve more symmetry?
3. What kind of material are the implants of?
4. How long is the surgery time expected for this?

Looking forward to your answer, as I’m very pleased with the orbital rim implant I have, but I don’t like that they are not fixated and they are a bit asymmetric with the crease and lump on left side. I want a permanent safer, smoother solution that also will cover more of my malar region as well.

A: My first comment would be that if you are largely satisfied with your current standard orbital rim implants, I would be cautious about making any change. As a general plastic surgery philosophy, ‘perfection can be the enemy of good.’ That being said, if you were to consider a change the only way you should do it is with a custom implant approach as this would be the only method that has any chance of taking a result that is largely good and trying to make it better. In answer to your custom infraorbital-malar implant questions:

1) I am very experienced with custom facial implants including having done many custom infraorbital, malar and combined infraorbital-malar implants. (the latter is the most common when using a custom implant approach)
2) In using a custom implant approach, symmetry is exactly one of its benefits. The computer can see the differences on your 3D CT scan in bone between the two sides as well as your current implant positions and shape and take all of that into consideration when designing the implants.
3) The custom implants I use are made of silicone.
4) My assistant will pass along the cost of the procedure to you on Monday.
5) This surgery takes 1 1/2 hours to complete.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom infraorbital-malar implants to replace my existing tear trough implants. Your initial statement about that I have to be careful when the result is “good enough”.But there is a couple of things that bother me with the current orbital rim implant.I already described the uneveness of the implants on the sides, but there is also this concern that the implant is not fixed. I’m a bit afraid that the fact that its not fixed could lead to some erosion,and that it would be better if it was fixed.

When you talk about the making of the custom implant, are you saying that a x-ray scan can detect the underlaying bone structure I have under the implant? So this would mean that there is no need to take the implant out first and then take pictures, but you can actually detect the structure under the implant and make a custom implant out of that information? If thats the case it would be a relief.

The surgeon that put in my current orbital rim implant said to me that he would not advice me to do another cheek implant surgery as this would be risky.

Again. thank you for being such a great doctor and giving me such detailed informative answers.

A: Custom infraorbital-malar implants are made from a 3D CT scan of the patient. From this scan the current size/shape/position of the orbital rim implants can be seen as well as that of the underlying bone. To make the custom implants the old implants are digitally removed for the new designs. Thus you do not need to have your old implants removed first, the computer program does it. The really informative thing is then the new implant designs are overlaid digitally on top of the old implants. (in different colors) By so doing the two implants can be compared and one can see both the differences as well as to keep the good things about the current implants and have the new implants cover the areas that the old one don’t.

There is nothing medically risky about a second surgery to remove and replace your current implants. The risks are really aesthetic in nature. But you can see that the custom implant approach would be the only way to lessen/eliminate those risks and give you the best chance to go from a good result to a better one.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reduction surgery. I would like to get the right side of my skull reduced. Its so bigger than the left side which is itself normal in size. This makes me look like big headed and I feel very uncomfortable with it.

So is there a possible way to do this surgery ?

What are the risks associated with it ?

How much can it cost ?

Will there be any scars after the surgery ?

A: Thank you for your inquiry and sending your pictures.  In answer to your skull reduction questions:

1) The right posterior temporal region can be reduced through muscle resection. This is a far more effective procedure for head width reduction than trying to reduce the bone.

2) In my extensive experience with this type of head reshaping surgery, there are no medical risks that I have seen or can envision. The aesthetic risk is how effective it will be and how much more symmetrical it will be to the other side.

3) The incision is made behind the ear in the sulcus area so there is visible scar at all.

4) My assistant will pass along the cost of the surgery to you tomorrow.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 24 year old male and, due to an untreated positional plagiocephaly in early infancy, the right posterior part of my skull is flattened showing the typical pattern of occipital postural plagiocephaly with an asymmetry of 6 mm between the two cranial vault diagonals. Since I got my hair shaved because of the incipient baldness, this flattening is more obvious.Thanks to the complete and invaluable information you provide on your website I think I have found a solution for my problem, a custom occipital skull implant, but I have doubts due to the particularities of my case.
 
The flattened area extends on the right side (viewed from the back), partially over the occipital and parietal bones, and slightly over the more posterior portion of the temporal bone. On the occipital zone, this causes a depression in the area surrounding the superior nuchal line where the occipitalis, trapezius, semispinalis capitis, splenius capitis and sternocleidomastoid muscles are attached. This is the area my question is about.
 
I understand that in cases of prominent nuchal ridge reduction these muscles of the superior nuchal line are detached for burring the nuchal ridge. I have also seen in the Web this kind of detachment in cases of anterior and lateral foramen magnum meningiomas surgeries where an extreme-lateral transcondylar and retrocondylar approaches respectively are performed, as well as in mastoidectomies.
 
My questions are:
1. The area corresponding to the attachment of the superior nuchal line muscles (the area delimited by the red line in the images) can also be augmented through a 3D custom-made silicone implant, or is there a maximum occipital inferior border to place the lower edge of the implant?
2. In which layer would the implant be placed? It will be directly placed on the skull bone and below the periosteum?
3. If the placement is subperiosteal and the nuchal ridge muscles are detached, how do the muscles are reattached to the skull if there is a piece of silicone underneath where they should be reattached? Does it have anything to do with the access being subperiosteal and lifting all the layers above the cranium like a flap?
4. Would detaching and reattaching the muscles cause muscle atrophy and, therefore, a reduction in its volume? If so, how can this unwanted effect can be camouflaged? Can detachment/reattachment affect the functionality of these muscles?
5. Can the implant be extended in one-single piece from the area of the upper nuchal line up towards the parietal bone?
6. Will the implant be fix to the bone with titanium screws?
7. Where will the incision be located in order to access the affected area?
8. The fact there is so little offer for cosmetic skull reshaping procedures around the world has something to do with the complexity of the procedure (technique, 3D custom implant supply,…), the lack of knowledge by the plastic surgeon about the existence of this procedure, the need for training as a craniofacial surgeon or maybe it is the little demand for this kind of cosmetic “job” (even when there is an increasing rate of people affected by plagiocephaly because of the “Back to sleep” campaign)?
 
Thank you very much in advance for your response.

A: Thank you for your inquiry and providing your specific skull shape concerns. Having done hundreds of skull implants of which the back of the head makes up half of them (of which those half are done for plagiocephaly), I can provide you the following answers to your occipital implant questions:

1) Augmentation of the occipital skull is NOT going to be done below the superior nuchal line. The contour below that line comes from the muscle not the bone and any detaching the muscle to have an implant extend below that line is counterproductive.

2) All skull implants are placed in the subperiosteal layer directly against the bone.

3) Once neck muscles are detached, they do not reattach nor can they be reattached regardless of whether there is an implant there or not.

4) Since the neck muscle can not be reattached and will cause some slight volume loss if so done, they should not be detached in any significant way. Hence why augmentation is not done below the superior nuchal line.

5) A custom skull implant can be designed to easily cover any contiguous skull area.

6) Most custom skull implants are secured with titanium microscrews.

7) A horizontal scalp incision, usually in the range of 7cm to 9 cms, is placed at the location of the nuchal judge in the hairline.

8) This does not appear to be a question but a statement for which I have no answer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a small mouth and it makes me very uncomfortable especially when I talk I feel like people are always judging me. Anyway I heard that you can do a procedure know as lateral commissuroplasty or mouth widening. Now I am aware of the trade off of scars and am not worried about it. What I am worried about is if it will look normal. I have never seen any before and after pics and I’m quite skeptical about it. If you could provide me with some information about the procedure to make up my mind. So my questions are, 1.will it look normal or will you be able to tell that its not 2. How successful is these procedure. Thank you very much.

A: Mouth widening surgery produces less visible scar formation than mouth narrowing surgery so it is a more favorable procedure in that regard. The procedure always makes the mouth wider, it is just a question of how much. The goal is to increase the width of the mouth by 5 to 7mms per side. It is really no different than an upper or lower lip vermilion advancement. It is just done on the normal corners of the mouth rather than the ‘north or south’ lip borders.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, is the laser used for eyelid lift? (aka Laser Eyelid Lift) Is this a real procedure?

A: The simple answer to your question is largely no. The concept of a ‘Laser Eyelid Lift’ is one that is more of a marketing concept and not an improved or contemporary blepharoplasty technique. Using lasers in surgery always sounds like it would be better but the reality is often very different. Using lasers to cut skin causes a thermal injury and a much worse potential scar than if ‘cold steel scalpel’ is used. Beside the worse scar outcome it does not make the surgery faster, cause less bruising/swelling nor expedite the recovery in any way. Due to the thermal injury to the skin’s edges they are also associated with an increased risk of after surgery skin edge separation (wound dehiscence) due to a delayed wound healing response. While lasers have a valuable role to play in facial skin resurfacing, they are not a useful technique for any facial surgery in which they are applied to cut the skin. They can be used to cauterize bleeding points and even help cut out fat during a blepharoplasty procedure, but they do not offer any real advantages over the traditional use of needlepoint electrocautery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a young Asian male whose brow bones are flat, and is seeking to get them stick out through brow bone implant surgery. Would there be any long and short term side effects through implants, considering the amount of delicate nerves that lies in close proximity?

A:The nerves to which you refer (supraorbital and supratrochlear nerves along the brow  ridge) are neither sensitive nor are they motor nerves. They are sensory nerves from the first division of the trigeminal nerve that exit out the brow bones and head north to supply the feeling to the forehead and the front of the scalp. They are very hardy nerves that are manipulated quite frequently in many forehead/brow bone procedures. In placing any brow bone implant around these nerves the implant design must consider their location so they are not compressed as a result of the implant’s placement. But this is usually an avoidable problem. This becomes a very relevant issue in the implant’s design if one is trying to drop down the brow bone edge inferiorly or desires a lot of horizontal (forward) projection. But fir the typical forehead/brow bone implant, a notch is made in the design of the nerve foramina based on the patient’s 3D CT scan.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. I am a 26 year old female that is almost 3 years post op from a sliding genioplasty. I’m unhappy with the results and original surgeon has offered to reverse it, but I have numbness and my lip has never returned to its previous position on the left side. I desperately want my previous smile back, but am extremely concerned about causing more numbness/nerve damage with a revision.

A: While I have no information about your chin other than your description, I would not count on ‘getting your smile back’ just because the bone is returned to its original position. You might but there is an equal if not greater chance you will not. You undergo a reverse genioplasty because you want the original look of your chin back…which will be a very likely outcome of a bone repositioning procedure. The smile is a result of dynamic muscular actions whose effects can not be assured by what happens to the bone as the soft tissues have been permanently changed from their being stretched. There is also the risk of creating further sensory loss of the lip although I do not consider this a major reason for not doing the reversal. Once the damage is done it is not likely to be worsened. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the tracheal shave procedure. I am a young female with a trachea that protrudes out quite a bit especially while looking up. I’ve been self-conscious about it for almost my entire life, since puberty. I’ve consulted with another surgeon and she believes she can go in through a scar I already have under my chin. I was curious if you’d be able to to do the same? I’d really rather not have a visible scar on my neck. Thank you for your consideration!

A:There are two approaches to the tracheal shave procedure, a submental and direct incision techniques. While there are two incisions to approach it, the reduction results will not be the same. Having done it both ways, the submental approach will achieve about 50% of the reduction that the direct approach will. The direct approach uses a 2.5 cm long incision in a skin wrinkle line right above or over the tracheal prominence. The submental incision uses a 3.5 cm long incision under the chin. It comes down to how much tracheal reduction you will find acceptable as well as the location of the fine line scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. I want to understand the differences between the materials that are used for skull augmentation and the risks. Can these materials cause infection or can your body reject it? Also, will they have to be replaced with new ones after a certain period of time due to breaking down of the implant material?

A: In answer to your skull reshaping questions:

1) The vast majority of skull augmentations I do are done with custom implants made of a solid silicone material. This is a material that does not degrade or breakdown unless exposed to very high heat. (375 degrees F or higher)

2) Any implanted material placed in the body runs the risk of infection. That risk for skull implants is very low due to the superb blood supply of the scalp and skull bone. I have yet to see an infection from a custom silicone skull implant.

3) Such skull implant materials do not develop rejection since silicone is one of the most biocompatible of all synthetic materials.

4) Silicone skull implants are permanent. They do not degrade or break down and thus never need to be replaced other than for aesthetic concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have typical flat back of head. I am interested in custom skull implant augmentation.What is full cost of augmentation. How many days would I need to stay there? Is it local anesthesia? I can’t seem to find anyone in this area that does this..if you know please tell me as I am concerned about follow up and tweaking. 

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

1) Assuming this is a one-stage custom skull implant procedure, I will have my assistant pass along the cost of the surgery to you tomorrow. How much augmentation one can achieve is based on one’s natural scalp flexibility to stretch to accommodate the implant. I would need of see side view pictures of your head and do some imaging to determine what type of augmentation change you seek.

2) Most patients return home within one to two days after surgery.

3) It is general anesthesia as no skull augmentation procedure can be done under local anesthesia if the implant has any size to it.

4) I can not speak for who else in the world does this procedure as that I am unaware of anyone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to get an idea of what my options would be should I need a custom facial implant revision should it end up being too big or too wide. How many months after surgery could the implant be reduced in size? 

A: When revising any facial implant it is first important to determine what its final size and shape will be. Thus it takes about 8 to 12 weeks to have all swelling go down, tissue contraction to occur and the patient to psychologically accommodate to the change. This is a process you undoubtably know well from your prior experiences. The other reason for the ‘3 Month Revision Rule’ is the quality of the tissues. Entering too early after surgery in intraoral incisions whose wound edges have not full recovered and returned to normal tissue quality runs a big risk of them not healing when traumatized too soon. As a result the incision may break donw, exposing the implant for which an attempt at secondary wound closure will not work for the same reason it came apart in the first place. It is important to remember that intraoral incisions are not like zippers, they can not be just opened and closed repeatedly in close time intervals and go on to normal healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to decide between having a facelift or getting laser resurfacing. I am using Retin A religiously and have seen improvement . Have been using it for a little over a month. I am supposed to have CO2 laser next month but I am not sure if I want to do that or have a face lift. I cant afford both so will have to decide which I want more. I know the laser will do nothing for the turkey neck or jowls but I also know the facelift won’t help my wrinkles. I guess what I am asking is what do you think I should do.

A: In discussion of the debate between laser resurfacing and a facelift, the question is what did you want to achieve. What each one can accomplish is going to be dramatically different. A lower facelift with improve the neck and jowls/jawline as well as help with some of the wrinkles around the jowls and at the side of the mouth. It will provide no improvements in the cheek or around the eye area. Conversely laser resurfacing can be done all over the face (but not the neck) and its improvements is to fine wrinkles and skin texture with very limited skin tightening properties.

The overall facial rejuvenation effect is far greater with a lower facelift as you may have suspected. I would think one would choose full face laser resurfacing instead of a facelift for surely economic considerations where the skin’s appearance can be improved even though the jowls and the neck sag will not be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal hollowing correction surgery. I have attached some pictures of my temporal areas. My temporal hollowing tarted after I had filler injected into my cheeks four months ago. I had one syringe of Voluma in each check, the “apple” area of the cheek only, but injected quite deep (near the bone).  On the left side of my face, some of the filler formed a lump which was sitting on nerves and causing pain and numbness in my face and severe pain shooting up into my head.  My temples began to disappear as did my upper eyelids.  The temple on the left side is worse since that is where the pain was more severe.  I went for several treatments to dissolve the filler.  The pain is not as bad now, but I still have pain and this is one of my concerns.  Because I am still experiencing pain in my head (including temple area), I don’t know if I should wait or try fillers first or fat transfer.  I don’t want to make the situation any worse. 

I would appreciate your feedback.

A: Thank you for sending your pictures and detailing your recent history. While I have done many cases of severe temporal hollowing correction before, your recent of history of acute temporal hollowing (due to fat atrophy) is not one that I have ever seen or heard of before. The exact mechanism behind such an acute and unprecedented temporal change can be hypothesized but the actual mechanism will probably never be known. (possible vascular compromise of the buccal fat pad??)

While I think temporal implants are the most effective treatment for your severe temporal hollowing, I don’t think you should do anything until your pain symptoms have completely resolved and the degree of temporal hollowing has stabilized. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  How long does the recover take for the Sagittal Crest Skull Reduction procedure? My husband and I would be flying in. He has been self conscious of this for a long time and has been looking in to it but I would like to know more about the procedure myself. 

1. How long would we need to be out there?
2. How long is his recovery?
3. By shaving down the bone will it increase the possibility of brain trauma later on if he were to have a head injury due to the bone being thinner?
4. What are the negative side effects?
5. How long have you been practicing the Sagittal Crest Skull reduction procedure?

A: I will provide some general answers to your questions with the understanding that I have no idea what your husband’s skull shape is or the extent of the sagittal crest issue. More specific answers that apply to your husband’s case would require seeing some pictures of his head for my assessment.

1) You would be able to return home the day after the procedure.

2) Recovery is merely about some swelling on the top of his head which will take a few weeks too largely subside. There are no other physical restrictions after surgery.

3) The crest bone that is removed  does not weaken his skull or make it more susceptible to injury or ‘brain trauma’ later.

4) The only potential risks (side effects) of the surgery are of an aesthetic nature…how much or well can it be reduced with good smoothness.

5) I have done many adult sagittal crest reduction procedures over the past ten years. It is one of the most common aesthetic skull reshaping surgeries that I do in men.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could you give me a bit more information on the infraorbital implants approach to undereye concerns? I’ve researched online and many sources state fillers/fat grafting as the best solution due to the high risk of asymmetry and unnatural appearance through implants. I’ve also heard that implants do not age well. Would these infraorbital implants also improve the appearance of my cheekbones (which are also relatively weak I think)? Thank you for your prompt and direct response.

A: In answer to your infraorbital implants questions:

1)None of the statements that you have read about infraorbital implants are accurate. They undoubtably come from providers who have either never performed infraorbital rim implants and only provide fillers/fat. The concept to grasp is that there are no true preformed infraorbital rim implants, only tear trough implants. Tear trough implants are not the same as infraorbital rim implants and are what surgeons may be only familiar. True infraorbital rim implants are custom made for each patient off of their 3D CT scan. Thus they fit the bone perfectly, have smooth transition into the surrounding bone, can be extended to augment the cheek as well (infraorbital-malar style) and actually elevate the level of the infraorbital rim. (standard tear trough implants only sit in front of the infraorbital rim and thus only augment it in the horizontal dimension…they do not cover the infraorbital rimin a smoother anatomic fashion and do not provide any height to the rim level)

2) In the treatment of infraorbital rim deficiency, the three treatments are synthetic injectable fillers, injected fat and implants. Each has their own advantages and disadvantages. But none of them are perfect nor is one method best for all patients. Each case must be considered separately and the magnitude of the defect considered in the treatment selection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have few more question since our last conversation related to custom silicone implant for back of the head augmentation.

It’s not urgent so please reply when you have some free time.

1. When the silicone implant is placed on the back of the head is there some bone erosion or bone resorption due to applied pressure to implant like in chin implants?

2. Edge of silicone implant is going to be very thin, but is there going to be any capsule formation and hardness around implant? Can it be felt with fingers?

3. How the the implant is going to be sterilized? I know that implant is sterilized by manufacturer, but is it sterilized in some way one more time before insertion?

4. Are silicone implants safer or unsafer than HDR and PEEK implants (or there is no difference) and is there some difference in how the body is reacting to theme?

5. If its need to be removed, does the scalp shrink normally?

6. The use of silicone implant for back of head augmentation is approved by FDA (Food and Drug Administration)?

7. Which company you are using for implant manufacturing (you already told me but i forget)?

A: In answer to your questions about a custom occipital skull implant:

1. Bone erosion or implant settling is not a phenomenon I have seen in skull implants.
2. All implants in the body get a surrounding capsule or layer of scar tissue. This is normal and is not the source of a palpable implant edge. The only method to reduce that risk is a feather edge to the implant which is done in the implant design.
3. The manufacturer sends the implant already sterilized.
4. All FDA-approved skull implant materials are similarly safe. One material is not ‘safer’; than another one.
5. All soft tissues contract when they are ‘devolumized’ when an implant is removed. Whether it will completely return to normal depends on the size of the implant and how long it has been in place.
6. All custom made silicone skull implants are FDA-approved.
7. Implantech

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if a vermillion or lip advancement can change the actual shape of the lips? I have a flat/undefined cupid’s bow that I’d like to augment along with the rest of the lips, but Juvederm only flattens thie cupid’s bow even more. Plus I am tired of spending money and to getting the results that I want. Every injector says that can make a better Cupid’s bow but it never happens. Thank you.

A: The main advantage of a vermilion or lip advancement is that it affects the whole lip, from corner to corner, and one can change the shape of the Cupid’s bow. Injectable fillers, like all volumizers, can only take the lip shape and push it out, it can not make a cupid’s bow that is ill-defined and flat and make it more defined or pronounced.

The decision you have to make is not whether a lip advancement will accomplish your upper lip reshaping goals…as it will. The question is whether the fine line scar that is the result of the lip advancement is a worthy trade-off. In most women with thin flat lips it is, but each patient has to make that decision for themselves.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry correction.  I just had lower jaw surgery for an underbite. I had the bottom jaw rotated to the left as my jaw was deviated a but, but even after the surgery was finished, I still had asymmetry. I want this issue fixed if possible. One side is strong, the other is not. I don’t know if you would reccoment making the strong side less so, or the weak side stronger. Also, I live in another state and could come down for the operation, but I don’t think I could bring anyone. After the operation, could a nurse drive me back to the hotel? How does that sort of thing work?

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

1) Mandibular osteotomies rarely fix lower facial asymmetry.They may reduce it but their movements are controlled/limited by the occlusion. You should wait a full three months after this surgery to allow the bones to heal and all swelling and soft tissue contraction to occur to fully assess the final results. I would need to see pictures of your face and eventually a 3D CT scan to determine how to best treat your jaw/lower facial asymmetry.

2) How best to treat the asymmetry (make the weak side stronger or make the strong side weaker) is best determined by computer imaging of both potential outcomes.

3) It is very common for patient’s to come by themselves and you have correctly assumed that our nursing service takes the patient back to their hotel if no overnight stay is warranted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry surgery.  I feel as though one side of my face sags down (the right). I have spoken to a facial surgeon in my city and he believes that it is natural asymmetry in my face but I believe it is because of my accident which I was in when I was five. He said that any surgery would be invasive and might not even change that much. Just looking for a second opinion and any options that might be open to me .Thanks.

A: Thank you for sending your pictures/. Your facial asymmetry is caused by a left-sided facial hypoplasia. (presuming the images are not switched)  It is natural only from the standpoint that it developed this way but that does not make it normal or aesthetically acceptable to you. This could be improved by the combination of a left jaw angle implant combined with a right perioral liposuction to better balance the two sides of the face. The other option for the soft tissues is to fat graft the left side of the face in the perioral  region based on how you want to balance out the soft tissue asymmetries. Yes surgery is invasive but that is the only way to improve your facial asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana