Your Questions

Q: Dr. Eppley, I came across this website and saw some before and after images of craniofacial surgery. (forehead horn reduction) I was hoping to get some more information on this surgery. I’m very uncomfortable going out wearing my hair off my face as my forehead appears to have two bumps on and if I do I’m often asked if i’ve hit my head, which I get quite embarrassed by. It would be great to get some advice and what actions I can take. I look forward to hearing from you.

A: Thank you for sending your forehead pictures. You have the classic ‘forehead horns’ that are benign paired bin bumps that appear on the upper forehead. They are development in origin and are actually not that rare. They can be successfully removed using of two approaches. The first approach is to simply burr down the prominences so they are more confluent with the rest of the forehead. (forehead horn reduction) The other approach is to build up the forehead area around the horns to make for a smoother albeit fuller or more convex forehead. The choice depends on the patient’s aesthetic preferences for their overall forehead shape

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. I have a very flat head from the back which makes my head look too small for my face and I need a big amount of augmentation to get the skull shape I’m looking for. After reading your blogs it seems that I need a 2 stage procedure using the tissue expander to get the maximal amount of scalp stretch needed for a good augmentation. I have few questions I want to ask you related to the 2 stage procedure

1.Are you the only one who preform skull reshaping 2 stage using Tissue Expander or it can be done by any skilled plastic surgeon?

2. Can an implant up to 3 cm be done if it was desired by a patient with a very flat back of head ?

3. Does this procedure performed by doctors in europe ?

4. My little brother has the same issue and his planning to get the procedure too when he will be able to pay for it. But he is very concerned if it’s gonna be available to him 10 years or 15 years from now?

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

I can only speak for the procedures that I do on a regular basis. I can not speak to what surgeons elsewhere in the world may perform a two-stage skull augmentation procedure.
2) It is usually wise to stay in the 2 to 2.5 cm augmentation thickness range.

3) I would not know if any doctors in Europe perform these type of skull augmentation procedures.

4) I see no reason why such skull reshaping procedures would not be available in the immediate or far future.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I need a lot of nasal dorsal augmentation. I looked at your gallery and like your work very much. And I would like to know if you would recommend rib cartilage or donated cartilage or artificial material in patients with very low nose bridge. Looking forward to hearing from you. Thanks!

A: There are three material methods of nasal dorsal augmentation, each with their own advantages and disadvantages. A synthetic implant, like ePTFE, offers an off-the-shelf augmentation material that can be carved and customized for each patient and offers an augmentation method that is assured of a smooth contour and not to warp after placement. But it does come with some risk of infection being a synthetic material. Autologous rib grafts offer the most natural material and lowest risk of infection. But it does requires a donor site, costs more to do and has some risk of warping and asymmetry. Cadaveric rib cartilage is like an intermediary material between an implant and one’s own rib cartilage. It is not an implant but then again is also not like one’s own rib cartilage either.

As you can see there is no perfect dorsal augmentation material and rhinoplasty surgeons often use what they are most familiar with or have used in the past. Having used all three nasal augmentation materials, my preferred choice comes down to educating the patient and having them decide which nasal material is most appearing to them. The only caveat in your case in that you said you need a lot of augmentation. I would have to see what a lot means as that may sway the decision in favor of one of the nasal augmentation materials.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m quite interested in getting custom zygomatic arch implants from you, but I had one major concern. I am currently aiming for two cosmetic surgery procedures: zygomatic augmentation with you and eye reshaping surgery from another surgeon. As you can see, the eye reshaping procedure might require anything from lateral canthoplasty to midface lifting/fat grafting under the lower eyelid. Since the zygoma and eyes seem anatomically close, my main concern was that getting zygomatic arch implants would reverse or affect the eye work I’d have done. Do zygomatic arch implants tend to impact or affect the eye shape or any eye procedures done prior to implantation? In this case, do you think there would be any reversal/affect risk from having the two procedures done? Which order would you recommend I do them in? Thanks so much.

A: I am not aware of any adverse effects of zygomatic arch implants on the lower eyelid. The dissection to place them does not violate the lower eyelid tissues. That being said it is clear that the zygomatic arch implants should be placed first as this will eliminate any potential lower eyelid concerns you may have as to their potential adverse effects.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. Several years years ago I had a chin reduction (sliding genioplasty 4mm). It left me with a short face and excess tissue. I then had a small button chin implant (2mm) inserted to try and reverse the outcome. I still have a short chin and excess tissue under neath my chin. Also from a side view it looks like there is an indent where the scar is and then tissue/fat. Also I have formed a jowl on my left side. I originally had a smooth chin/neckline. I’m wondering if it’s possible to do a sliding genioplasty with the small implant still intact. (mainly vertically 2mm) to help the short frontal view. I’d like to look more like my original face (never should have started down this road). Will a sliding genioplasty help the excess tissue? Will it tighten my neckline? Is it possible to do a sliding genioplasty with an excision under the chin instead of intraoral to try to avoid complications with the lips? Thank you for your time. 

A: The answer is you can do a sliding genioplasty with a chin implant in place, I have done it many times. This is the correct procedure to pick up the loose tissues and improve your jawline. Remember a sliding genioplasty setback (which never works satisfactorily for a chin reduction) got you where you are today…and only reversing it is going to help get you out it. (sliding genioplasty reversal) It will have to be done intraorally and not from a submental approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast augmentation  in 2006 in which round, saline, high profile implements were placed under the muscle. As you can see on the picture the implants are too narrow, too far apart from each other and not low enough which is one of the reasons why my nipples are too low. Also, when flexing the implants they move way too much (see pic) and when lying the left implant migrate externally (see pic). So what I’m looking for is a surgeon that could make do a breast augmentation revision as well as lifting my nipples of 2 cm whithout scaring the hell out of my breasts. So I was thinking that a capsulectomy with new lifting anatomical implants could be a solution? Or reducing my capsules In order to prevent the anatomical implant from moving could be an other one?

What do you think Doc?

A: Thank you for sending your pictures. I would agree that your breast implants are sitting too high and have a fairly narrow base. Because they are probably 100% submuscular you have a more complete expression of the implant animation deformity. (which every submuscular patient has to some degree) Through your existing inframammary incisions, new breasts implants that have a wider base (some increased volume as well) placed into new pockets which are lowered and with some partial muscle release, should address most of your concerns. The only one that would not be a lot better is the spacing between your breasts which is a reflection off your natural breast base spacing. I would avoid anatomic implants in a breast augmentation revision due to potential implant shifting. If needed I would also perform a superior crescent nipple lift as part of your breast augmentation revision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock implant replacements. I have had two prior buttock implant surgeries The first was using 500cc subfascial implants which looked abnormal and then there were replaced with 712cc intramuscular implants which also do not look right and give me a lot of pain. What do you recommend for buttock implant replacements?

A: At 712ccs of volume I can assure you that your current buttock implants are in the subfascial location not the intramuscular location. My thoughts are as follows:

1) Stay in the subfascial pocket which is undoubtably where you are now with your 712cc implants.

2) Use a parasagittal incision approach rather than a single midline incision. This will lower the risk of wound separation after surgery and also prevent any communication between the two implants.

3) Round implants do not have the risk of rotation/malposition that anatomic or oblong ones have.

4) Your current 712cc implants have a 15.7 cm base with 6cm projection. That is too narrow an implant diameter for that much projection in a visible subfascial location.

5) New buttock implant considerations include either a) custom made implants with a 16.5 cm base of 500cc volume or b) stock oblong implants of 575cc volume with 20cm length and 15cm width.

6) Ideally you want new implants that can fill or stretch out your existing pockets/capsule so it does not need to be adjusted/reduced with less implant volume as this is an unpredictable and unstable maneuver in the buttock region which has to eventually be exposed to the stresses of sitting.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, at what time period can infection be ruled out in custom facial implants?  Like three weeks?  I am worried about second hand smoke from people causing infection, I’ve never smoked in my life but am worried about that. 

I was wondering what is done in the case of infection with custom facial implants, do they always have to be removed or do the infections sometimes clear up?  What can I do aside from taking the prescribed antibiotics in order to help prevent infection? 

A: The treatment of infection in custom facial implants is no different than that of any other implant placed in the body. The only effective treatment options s is to either remove the implant or clean out the wound, re-sterilize the implant(s) and immediately re-insert it. The infection never gets cleared up by any other maneuver. it is critically important that he biofilm layer on the implant be completely removed if any treatment is to be effective.

Second hand smoke is not a cause of infection. Other than talking antibiotics and using Peridex mouthwash, there is nothing else you can do. 

The risk of infection is never completely ruled out for 6 to 8 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in your custom sternal implant surgery for pectus excavatum. How much would the surgery cost for a 3D computer design, compared to a silicone elastomer moulage technique? Also, what is the difference between the two?

A: To make a sternal implant in the contour treatment of precuts excavatum, the two approaches are as you have mentioned are a moulage and 3D CT scan design. In general a sternal implant designed from the patient’s 3D chest CT scan provides the most accurate implant shape based on the actual shape of the sternum and medial ribs. In contrast a moulage implant design is an external technique using the shape of the sternal depression. While not exactly mimicking the underlying bone shape it still provides a pretty good contour restoration.

I  have used both techniques and I can not tell you that one is absolutely superior to the other in terms of the aesthetic result. Thus the technique I use for sternal implants is based on the patient’s geography. If they can be seen in the office I will use the moulage technique as I can make it myself. If they are geographically distant I will either use a 3D CT scan design or have the patient make their own clay or silicone elastomer moulage of the sternal depression. ( I send a silicone elastomer kit to do it)

My assistant Camille will pass along the cost of the surgery to you next week. The only difference in the cost between the two custom sternal implant techniques is the cost of the implant fabrication.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I am interested in flank liposuction. I had a tummy tuck ten years ago and have had these muffin tops since. I probably had them before but they have become more pronounced since the tummy tuck surgery. I’m otherwise very active and exercise regularly but these muffin tops are unrelenting and simply won’t go away. I hope that Smartlipo can get rid of them. I have attached some pictures for your review and recommendations.

A: Thank you for sending your pictures. The reality is that a significant portion of your muffin tops is caused by excess skin and not fat. While you can undergo liposuction that is very likely going to lead to a disappointing result as there is simply too much skin. No form of liposuction can shrink 10 to 12 cms of excess skin width. The only really effective procedure is going to be flank lifts where a wide excision of the skin rolls is done. You probably originally should have had an extended tummy tuck to address these rolls at the time off your original tummy tuck but either weren’t prepared to accept the extended scars or your surgeon never offered that as a tummy tuck option. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year old man and I would like to make my chin area more developed to enhance my overall look. I believe the lower third area of my face isn’t very strong, This could be corrected in the form of a sliding genioplasty or a chin implant, your opinion on what needs to be done would greatly matter. 

I look forward to your reply.

A: Compared to almost all patients that I have seen for chin augmentation, you actually have one of the ‘stronger’ chins. Probably what you are seeking is both a horizontal and vertical chin change. Thus you could go either with an implant or a sliding genioplasty depending upon the following two considerations:

1) From the front view do you want to keep the chin the shape that it is or have it be more square which would require a square chin implant style

2) Your personal feeling about a synthetic implant or whether you feel more comfortable using your own bone for the chin augmentation

The answer to those two question will decide which chin augmentation method is best for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the flash recovery breast augmentation procedure. However, I have a few concerns: I have tuberous breasts, and I am transgender. Does Dr. Eppley specialize in tuberous breasts, and is it a problem that I am transgender? I have all the necessary paper work and documentation. My big goal is to be able to achieve “kissing cleavage” even without the need of a push up. I’m also wanting to go as big as possible, so how big can ideal implants get? A couple of surgeons suggested 800cc uhp silicone since I have a wide frae and it would eat it up easily, but when I tried on the sizers they just didn’t have that vavoom look I was wanting. I don’t really want to go saline because I still want that natural jiggle I have now. Thank you for your time!

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

1) I believe you are referring to a Rapid Recovery breast augmentation protocol as opposed to a Flash Recovery. While breast augmentation recovery can be expedited, it can not be instantaneous.

2) Whether one is a genetic female or male, breast implants can be successfully placed. There may or may not be size limitations based one the ability of the tissues to stretch to accommodate the implant.

3) Tuberous breasts are not an infrequent finding in prospective breast augmentation patients. Depending upon their severity they can impact how the breast augmentation procedure is performed and the results seen. No plastic surgeon ’specializes’ in tuberous breasts, they either have experience with them or not. Most plastic surgeons have.

4) Whether you can achieve cleavage from your breast augmentation depends on many anatomic factors and not just implant size alone. Implant size helps but one’s natural breast and nipple spacing plays a major role as well.

5) The largest silicone breast implants are 800cc. Only saline implants can go bigger. Depending upon your implant size needs, you may have no choice but saline implants ion 800cc is inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a healthy 51 years old man and underwent a cheek implant procedure 15 years ago. The surgeon used Implantech´s Flowers Tear Trough implants, I am almost certain it was the size FTT-L  Large (4.8 X 2.6 X 0.5 cm).  He also suggested two nasolabial fold implants (those are quite small and he made them himself) and I accepted.

The problem is that, even though I have looked reasonably well up until now, the cheek implants where misplaced from the beginning.  The right cheek implant is too high, tilted and very close to the eye and the left implant too low.

The nasolabial fold implants are also misplaced (they were inserted through my nose, and I think it was the nasolabial implants that made recovery quite difficult due to extreme and swelling that lasted very a very long time).  Anyway, those implants go pretty much unnoticed and I only found out about their misplacement when I had a 3D face scan done recently.

I am in good shape, exercise, don’t drink or smoke, no heart or any other major issues whatsoever and have a normal build with about 20% of body fat.  I lost a lot of weight – 25 pounds, from 185 to 165 pounds, thus becoming quite skinny – a few years ago and I started feeling some pain in the cheeks.  I don’t know whether it was the cause, but when I regained my weight, the pain disappeared.  I thought that the loss of fat in my face was the cause.

Today I look younger than my real age, and I my cheeks look fairly good, but I fear that as I age, the asymmetry will become more apparent.  I was very interested on the idea of having customized implants that fit perfectly the shape of my cheeks and therefore will look natural no matter how thin my skin becomes in the future (or that’s what I guess).

I know that over the years, tissue grow around the implants and it becomes more difficult to replace them, so I don’t know how feasible my case would be or if you’ve had similar cases that wanted their implants replaced after so long.

Finally, I wonder whether having implants already in place would make more difficult to measure the cheeks and create new custom implants or if that fact is irrelevant to it. 

Also, I would like to know what the steps would be.  Could they be extracted and replaced in the same procedure?

A: Thank you for your inquiry and dealing your facial implant history and current concerns. In answer to your questions on your cheek implants:

1) Indwelling cheek implants do not make the surgery any more difficult regardless of the natural scar tissue which develops around them.

2) Indwelling cheek implants do not interfere sth designing custom ones as the existing implants are digitally removed. Actually they help in the design of the new ones since one can see where the old ones are and what they look like. When you know what doesn’t work well, it helps in making new implants designs to be better.

3) Cheek implant removal and replacement is always done at the same time.

If you have a current 3D CT scan please send me the actual disc as that is what is needed to make the new cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, ]I have pectus excavatum – I see on your site you mentioned the option of 3D implants to treat the sternal depression part of it. (custom sternal implant) Do you have any photos you could send me of your work with those? Have you ever done 3D implant on a female with Pectus Excavatum? The midline between my breasts is very narrow.. Do you think breast implants would be better choice? Do you have any pics you can send me of any patients with pectus excavatum that you placed breast implants in? Also where do we get fitted for a 3D implant?

Looking forward to your response.

A: Most cases of more minor pectus excavatum in females is adequately managed by breast implants. But it would depend on the depth of the sternal depression. I would need to see pictures off your chest to provide a more qualified answer as to what many be best for you. Breast implants work by making larger mounds and, as a result, the sternal depression usually looks less. The other treatment option is the making of a custom sternal implant designed from either a 3D CT scan of the sternum/ribcage or in office sternal moulages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had facial feminization surgery as part of my gender transition approximately six months ago. While I am very happy with the result overall, there is one problem: My lips do not meet at rest due to a labial gap of around 5.5 mm. 

Prior to my facial feminization surgery, I had double-jaw surgery to correct an open bite and a gap between my lips at rest. This surgery was 100% successful. I then had the feminization procedure which included jaw contouring, a sliding genioplasty, and an upper lip lift. While my lower lip is no lower than it was before the surgery (as far as I can tell) and I do not think anything was damaged, the upper lip lift is once again making it difficult to close my lips. 

I am trying to figure out if I am a candidate for mentalis muscle resuspension. (I know that it was not relocated as part of my genioplasty.) I spoke with a doctor here in New York and he believes it would help, but I’m not sure he’s the right surgeon for me and I’d like a second opinion. 

A: Just by your description it is not apparent that a mentalis muscle resuspension would be beneficial. Unless you have obvious chin ptosis, mentalis muscle manipulation is not going to improve lower lip incompetence in my experience. Unless the muscle is sagging (chin ptosis), you can’t lift the muscle past ‘normal’. Driving up the position of the lower lip requires multiple maneuvers and trying to change a normal muscle position is not one of them.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I have an interest in getting a mentalis muscle resuspension. I recently underwent a sliding genioplasty procedure and a few weeks later noticed that my lower lip began to be pulled down. I now have trouble keeping my mouth closed. I have been doing some research on mentalis resuspensions but it seems like most of the cases I’ve seen the lip position stays in place for a while but eventually falls back down. If permanent fixtures are placed and the mentalis is sutured to the fixtures, how can it fall back down? What causes this to happen? Also, what causes the sulcus to deepen and how can you bring it back to normal. Thanks and I hope to hear from you soon.

A: Mentalis muscle resuspension has a high incidence of ineffectiveness and lack of sustained long-term results. I would be particularly unenthusiastic about any success after a sliding geniopalsty where the tissues are already stretched. Deepening of the labiomental fold is an expected and natural sequelae of moving the chin bone forward.

The only surgical approach that I think has any merit is a dermal-fat graft to the labiomental sulcus placed intraorally and above the mentalis muscle.

Dr. Barry Eppley

Q: Dr. Eppley, Ten years ago I had a cheek reduction done in South Korea. Beginning 2 years ago long after the operation, I developed right ear pain and a numbing sensation which often persists all day, a kind of burning, tingling towards the end of the right outer ear canal. It is not a spontaneous, penetrating stabbing pain attack, such as trigeminal neuralgia, but a duration of pain. This pain is very unpleasant. 

I really hope to gain a better understanding of the cause of the pain. What I cannot understand at all is why the pain did not occur immediately, but so many years later.I guess that the hardware (screws and plates) is responsible for the pain. That’s why I had two operations to remove them. Unfortunately, they could not completely remove it.

Since I have heard a lot of positive things about you, I wanted to ask you if do you think that the pain is triggered by the hardware still present in the face and and whether it would be the best for me to remove the remaining screws and plates.

I can send you also some current radiographs. I would greatly appreciate it if you kindly give me a short reply on this.

A: As you know, it would be very unusual to develop these symptoms in such a delayed fashion from cheek reduction surgery. That alone suggests it may have nothing to do with the surgery at all. Indwelling hardware is not known to produce such symptoms although they remain an understandable target since they are in proximity to the symptomatic site and can be identified radiographically. I would need to see the radiograph you have to make any further comment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is it possible to get custom cheek-infraorbital implants done for the aforementioned region with a thickness inferior to the 2mm (like in the 0.5 – 2 mm range)? I am young, but I have a thin face with very little facial fat volume, and I really think that medium sized implants would look already excessive on me. Thank you very much for your attention!

A: Custom cheek-infraorbital implants are made from the patient’s 3D CT scan using implant design software. They can be made as thin as about 1.5mms. Any thinner and it poses manufacturing processing problems. Even if they could be made thinner, there would be no practical reason to do so as a 1mm or less  change on one’s face would not be detectable and this would not be worth the surgical effort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant removal. I had a breast augmentation done in April of last year by you. I had 375cc round moderate plus silicone implants. I am 5’3 and 105-110lbs. I am considering breast implant removal just because I don’t feel like myself. I was a 32B previously. I haven’t had any issues with them. I love the results and think you did a wonderful job. I just don’t feel like myself and am considering getting them removed. It is faster to contact me through email. Thank you so much! 

A: Thank you for the long-term follow-up on your breast augmentation. I don’t really have much to add to your desires as this is just a personal choice on your part. I would say that it is also important to know that your breasts will not return completely to their presurgical shape due to some tissue stretching. Their preoperative size may return but they will feel ‘looser’ with a little more stretch of the breast tissues. Whether that will be a significant aesthetic issue for you after surgery can not be predicted before their removal.

Ultimately this is a very personal decision and very rare in breast augmentation surgery. But just like in facial implants an occasional patient just not feel or like themselves and undergoes removal of the augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in getting a Body Lift. I’m 5’8″ and 115 lbs with not a lot of extra fat. What does the Body Lift include? Would be interested in buttock/breast augmentation, but I’m 50 years old. Very unhappy with my appearance. Thanks!

A: When one uses the term ‘Body Lift’ this typically refers to bariatric patients who have lost a lot of weight and have much loose hanging skin as a result of a general body deflation. Body lift surgery is when much of this hanging skin is removed around the waistline and the body is lifted, much like pulling up one’s pants that have fallen down. At 5’8″ and 115lbs I don’t think you are referring to classic Body Lift surgery.

I suspect what you really mean is that at your very lean weight you do not have much of a figure due to a reasonably low body fat content. Thus you have specifically identified breast and buttock augmentation (breast and buttock implants) to help create some ‘curves’ so to speak. Such body augmentation may indeed create a form of body lift in you. Pictures of your body would help clarify what you exactly need in your quest for a ‘Body Lift’ procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to remove excess fat from flanks, abdomen and pubic area. I’m looking for minimal scaring and  down time. (not looking for traditional liposuction, more like Smartlipo) I have attached some pictures of my areas of excess fat concerns. It would be great if I could have the procedure on Friday and be back to all normal things by the following Monday. 

A: Thank you for sending your pictures. While fat reduction by liposuction can be very effective for your concerns, you are mistaken about how it is done. Any form of liposuction is going to entail the identical recovery and downtime. All forms of liposuction are invasive and traumatic, including Smartlipo, and should never be considered ‘minimal downtime’.  Anything that leads you to believe otherwise is marketing promotion and is misleading by whomever wrote or said it. In short there is no easy way to get rid of a lot of fat. Liposuction surgery is still the most effective way but it is a surgical process with significant trauma to the body and a very real recovery. Smartlipo is not different in this regard no matter how it is promoted or marketed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am exploring the temporal artery ligation procedure and wanted to ask a few quick question. 1) How many such procedures have you undertaken? 2) Where is the blood flow diverted to when the temporal artery is ligated? What are the chances that other veins visible on the forehead will swell/dilate in response to increased blood flow? 3) What is the estimated cost to have the procedure done on both sides of the head? Thank you.

A: Temporal artery ligation is a diverse group of procedures whose each number of ligations points will vary per patient. I have done over 50 patients for these type of ligations and each one is unique in some way. I would need to see pictures of your temporal areas that show the visible vessels for an assessment. Ligating temporal vessels at any point along their course does not divert the blood flow. Rather it dampens or eliminates the pulsations and visible arterial course by shutting off flow into that section of the vessel along its prominence. I have not yet seen that such ligations promote dilatation of other surrounding vessels particularly when the ligations are distal to the main trunk of the superficial temporal artery.

I will have my assistant pass along the general cost of the procedure to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been struggling with the depression in my forehead, there’s irregularity like a W where the bones right above my eyebrows seem to be swollen to the outside with a depression in the middle.. It makes me look as if I’m frowning all the time. I’m looking for a permanent solution to my problem. Is there one? Is there such a thing as a glabellar implant?  If so will you please advise me of the price and if insurance would cover even part of the treatment? I have attached 2 pictures, please let me know if they aren’t clear enough.Thank you so much doctor.

A: Based on the pictures you have shown and by your description, this is most consistent with a glabellar bony depression between the medial (inner) ends of the brow bones. This is a much more common lower forehead shape in men than in women. I will assume that you have tried Botox injections so we know that it is not problem that is solved by muscle relaxation.

Assuming that the shape of the underlying bone is the main culprit, your options are two fold. One approach is with fat injections to thicken up the vertical soft tissue indentation. The potential success of this approach can be determined before surgery with simple saline injections. While this is the simplest method of tissue augmentation its ultimate success depends on how much fat takes and persists…which can be unpredictable.

The second approach is the placement of a glabellar implant. Inserted endoscopically through small scalp incisions. Such an implant fills in the depression or hollow between the bony eyebrows. Its volume retention is assured. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about my rhinoplasty recovery. I recently had surgery on my nose for a breathing issue out of the left side of my nostril and am 3 1/2 months post op, I was diagnosed with a collapsed septum and was recommended Septoplasty. I was referred to a local Otolaryngologist from my in network primary care physician and inquired about the surgery. At the time of the consultation I asked if a small spur on the side of my nasal bridge could also be removed (Not the dorsal profile) while they preformed the surgery. I was told it could and envisioned the nose I had without the spur and better breathing functionality, unfortunately now post op I feel my profile has been changed and my nasal tip now seems more lifted and my nostrils are more visible. I also believe my nose has been narrowed and appears wider due to the dorsal line being adjusted. My nose also appears crooked due to the refined definition. Along with that I am experiencing swelling in my top lip and from eyebrow to eyebrow with a tight discomfort in the middle of my head. With all that being said here are a few questions I have:

1: Can I expect my nasal tip to drop as the swelling subsides and when the swelling subsides and the skin relaxes do things expand?

2:Do you personally have any experience with a patient who has experienced tight swelling and discomfort in there forehead and lower lip for that long of a time frame? It’s been present since surgery.

3: In regards to revision surgery after the swelling subsides and if I am still unhappy can the profile be restored?

I have attached a comparison photo.

Thanks In advance.

A: Thank you for your inquiry and detailing your recent nasal surgery. As I have no knowledge as to what was actually done structurally during your nasal surgery I could not remotely comment on what its long-term effects would be. I can, however, make some general statements about rhinoplasty recovery:

1) Whatever nasal tip decent is going to occur, it will most likely have occurred by six months or so after the procedure.

2) The persistent tightness sensations in the forehead are not symptoms that I recall having had a patient mention before.

3) Tightness in the upper lip, however, can be present after surgery and can take months to subside…depending upon what was actually done.

4) Profile restoration and tip derogation can always be done secondarily if needed.

I would give yourself a full six months and then ponder #4.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about my jawline implant recovery. In terms of the swelling, it has gone down dramatically and almost feels like it used to before surgery. I also finished my antibiotics, and I no longer take any advil or pain medication (just a little pain when I eat). Since I have been exercising regularly (including cardio) is it possible that the swelling goes down more rapidly then more sedentary folks?

I am looking at my reflection and it looks like the face is a bit longer and leaner looking and has a bit more prominent cheekbones and chin; however, I am already starting to think we might have wanted to go with a more projected, square chin and a bit more flaring jaws to make the face look more masculine. I will reserve final judgement until Memorial day, as you mentioned. Do you think it the shrinkwrap phase will make the face resemble the images we photo shopped as time goes on? Any thoughts about what I’m seeing currently?

A: Thank you for the early progress update. At just three weeks after surgery, it is not possible to have all of your facial swelling to be gone…maybe 70% or so but it not a complete process yet. To help you with some practical milestones, here is what you should be looking for in your jawline implant recovery:

Phase 1 – One month afer surgery – resolution of 80% of swelling, healed incisions with loss of most of the sutures, restoration of completely normal mouth opening and return too full diet, no signs of infections (most infections occur within the first month after surgery.

Phase 2 – Two months after surgery – resolution of 100% of swelling, onset of shrink wrap effect with ongoing presentation of implant definition, normal feeling of most facial areas, no signs of infection (if there is no infection by this time this possibility is very unlikely)

Phase 3 – 3 months after surgery – shrink wrap effect complete, psychological adaptation to new facial appearance complete.

As you can see by this timetable and milestones, this is an evolving process that is to fully complete until three months after surgery. You are only approaching the end of phase 1. How phase 2 and 3 will affect your perception of the result remains to be determined. 

On a final note, as I have mentioned before, how the implant dimensions and the results they will create will turn out is not an exact science. We have made the best guesstimates we could with the over riding design principle that we don’t want the implants to be too big. How successful we are in that regard awaits the completion evolution of the recovery process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need advice. I want a permanent solution to my thin upper lip. I had braces as a child but still have a toothless-looking, thin-lipped resting expression. When I smile or make sure to hold my mandible apart, I have a nice mouth, and I have had small amounts of restalyne before that did not last long. I want a permanent solution and need to know if implants are the answer or a dental procedure of some kind. Thank you!

A: Thank you for sending your lip pictures. Lip implants work best in patients that already have adequate vermilion exposure…which you do.  The implant needs enough vermilion tissue to be able to safely surround the tissues and to push both out and up. So I think you are a good candidate for a Permalip implant in your upper lip if you are looking for a permanent augmentation method.

Permalip implants, like all facial implants, have their disadvantages of which asymmetry or implant malposition is the most common. Its smooth surface allows for good introduction and passage through the tissues and for uncomplicated removal if needed. But this very smooth surface is also what causes it to short inside the capsule in some patients.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation to create a wider, more masculine forehead with a custom implant. My forehead is very narrow and convex for a male. From my research I’ve come to realise that my limiting factor is the positioning of my anterior temporal lines. They are too close to the centre of my forehead. I know that designing an implant that extends beyond these lines may be aesthetically problematic. Is it possible to design an implant that covers both the temporal and forehead areas to sidestep this issue? How important is the ‘crossing the anterior temporal lines’ issue? Is it a completely preclusive one, or may the patient insist on going through with widening the forehead regardless?

A:When it comes to forehead augmentation, crossing the temporal lines with the traditional use of bone cements was always problematic because it was impossible to get a smooth transition into the the temporalis muscle area. (which is what lies on the outside of the temporal lines) But with the use of today’s custom forehead implants made from a 3D CT scan, where the edges can be made very smooth, such transition concerns are now minimized. This creating a wider or more lateral anterior temporal line demarcation can now be reliable done in an aesthetic manner.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jawline reshaping. I had a chin implant two years ago but it did not help me with the desired look which is not my chin but a weak jawline. I have since tried Kybella but had minimal results. I think jawline implants would possibly address the issues I have with my jawline area. I attached some pictures I pointed to the areas that bug me the most. The fourth pic is how I would like my face to look more tight and defined. I would love to know your thoughts.

A: Thank you for sending your pictures to illustrate your concerns. You have several different jawline reshaping approaches to consider for an improved jawline.

1) Jowl Tuckup procedure. What you are illustrating with your finger is jowling, the development of a soft tissue sag in the middle of the jawline. A mini-lower facelift or jowl tuck is what really solves that soft tissue drape issue hanging off of the jawline by pulling tissues back along the jawline towards the ear.

2) A weak jawline is often perceived as a lack of defined jaw angles, which you are illustrating in one of your pictures. (technically you are illustrating both a jowl tuck and a jaw angle implant(

3) The combination of #1 and #2 is also a possibility.

Dr. Barry Eppley
Indianapolis,

Q: Dr. Eppley, I am interested in cheek implant revision. I had cheek implants put in in ten years ago by a local plastic surgeon.  I originally went to see him because I had puffy cheeks and I did not want that baby-face look, so he suggested putting in submalar-malar cheek implants. The look I was going for was not achieved as it made my face look more full instead of narrow like I told the doctor I wanted.

The left implant either shifted up or was not put in correctly which caused one side of my face to be uneven with the right.  There was also some type of nerve or muscle damage because my smile on the left side would droop down, almost like I had a stroke.  There is still a little scar tissue that has formed around the implant.

I am considering the following options to achieve the look I’ve wanted from the beginning:

Option 1:

Slightly lower the left implant so it looks even and contoured to my face, like the other side.  Have some of the fullness in my cheeks taken out by removing the fat.

Option 2:

Remove the implants and have the fat removed from the cheek area.

Option 3:

Have new implants put in and have the fat removed from the cheek area.

I know option 3 will most likely be out of range for me to afford, and option 2 will most likely leave my face looking flat and my skin sagging where the implants were.

A: Thank you for your inquiry regarding cheek implant revision  and sending your pictures of concerns. First, the concept of putting in combined malar-submalat cheek implants was never going to make your face more narrow or sculpted. They are a cheek implant style that will give you an ‘apple cheek’ effect, an area of midface augmentation that appeals to some women but very few men in my experience. Second, cheek implant asymmetry is very common as the placement of any two-sided implants in the face or body is very difficult to achieve perfect symmetry particularly through the limited access of an intraoral incision.

That being said, my comments as to your listed options:

1) While cheek implant adjustment can be done, these existing implant styles do not appear to be achieving your initial objectives. Thus adjusting the left cheek implant may improve their symmetry but would not may the overall desired look any better. Whether taking out the buccal fat would be helpful remains to be seen. This is an approach that offers the simplest and least risky choice but also one that has the least aesthetic gain.

2) Without some cheek prominence removing buccal fat would provide little if any aesthetic improvement.

3) This would offer the best chance for real change and to get you closer to your aesthetic midface goals. The key is the cheek implant styles…which was the same important issue prior to your first surgery.

Since you mentioned cost, Option #1 would definitely in my option be better than Option #2.

There is also an Option #4. Treat both existing cheek implants (as well as adjust the left cheek implant and the buccal lipectomies) by getting rid of the submalar portion of the implants which is not helping your facial aesthetic goals.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am 32 years old woman. I am interested in skull reshaping surgery because my head is very flat on top. I want to ask if PMMA is also Osteobond? How does Osteobond differ from PMMA? And is it possible for Osteobond to give toxic reactions to the body in future like 40-50 years later? Because I have read somewhere that some Osteobond in orthopedic surgery caused arythmia, blood hypertension and heart attack for old patients. And what will be the approximate price for top of the head augmentation? I will be looking forward to your reply. Thank you for your time and consideration 🙂

A: Thank you for your inquiry. PMMA is a generic name for polymethylmethacrylate, a well known material used in orthopedics as a true bone cement to hold in place joint replacements and is also used as an onlay contouring material in the skull usually under the name Cranioplast. Osteobond is one variation (copolymer) of PMMA but it is a polymethylmethacrylate material. Do not confuse what can happen when such borne cements are injected under pressure inside a long bone with applying it softly on top of the skull bone. Such bodily reactions as you have described do not occur in cranioplasty use.

That being said I have largely abandoned the use of PMMA bone cements for custom silicone skull implants which offer superior shape, smaller incisions for placement and no potential adverse effects on the bone.

Dr. Barry Eppley

Indianapolis, Indiana