Your Questions

Q: Dr. Eppley, I am seeking gynecomastia reduction revision surgery. had a perfect chest, and put on some weight and thought gynecomastia reduction surgery would be the answer for puffy nipples and getting it more defined. Well the surgery went wrong and I ended up with a nipple indent, scarring, hepatoma and a  crater deformity. I then went to another doctor who does revision gynecomastia reductions who said no to pectoral implants but could fix the crater and make it look good. But he ended up over doing liposuction leaving me with less tissue, a caved in look and puffy nipple on the left side which looks still like I have gynecomastia.

The right side is more natural and fuller but left side just doesn’t match it. These doctors were supposedly the best and I am left deformed. I wondering if you looked at my pics and get your opinion. I find the left side the worst with the puffy nipple and more fat missing as this is the side I did’t have the hematoma. 

Was wondering if you were able to make my chest more defined again and both sides even looking.  thanks 

A: Thank you for your inquiry and sending all of your pictures. I am not quite sure how you started out with a relatively small gynecomastia problem and ended up where you are now after multiple surgeries. But that is irrelevant now as all that matters is where you can go from here. I think your gynecomastic revision surgery options depends on how much restoration you want and how much effort you want to put into it. This means the following:

1) With your complicated gynecomastia reduction/liposuction history it would be perfectly understandable that you would want to do the least amount of further surgery that has the lowest risk possible. In that case I would only treat the left side with either fat transfer or a dermal-fat graft. Fat injections have the lowest risk as the worst case scenario is that it doesn’t work well. I don’t know if you really need to put on weight as even in thinner males enough fat can be harvested from the inner thighs to do a small area like the left nipple/lower chest. This would produce the least aesthetic improvement with the only goal being to make the left side look closer to that of the right.

or

1. On the opposite end of the treatment spectrum are pectoral implants. Both sides of the chest are really deflated with loose skin. This loose tissue exacerbates any soft tissue deficiency between the two sides. Pectoral implants would expand both sides of the chest and would offer the best chest improvement. Whether some additional work needs done on the nipples at the same time remains to be determined. But with the option for best overall chest improvement comes this ‘bigger’ surgery with its own attendant risks. At this point with your surgical history, this concept make be too much to consider even if it offers the best aesthetic improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in finding out how much would it be to have liposuction done to get my buttock injections removed. I’m having a lot of pain and discomfort and it seems as though the sillicone is moving down my leg and there is a lot of pressure being put on my tail bone when I sit and it’s causing a lot of pain. Can you please help? Do you all offer these services?

A: The long-term sequelae from silicone oil injections into the buttocks can include chronic inflammatory reactions known as granulomas. They can cause pain, hard lumps, skin discoloration and even open draining areas.

The typical treatment for silicone oil buttock injections is a combination of liposuction and fat injections. Buttock injection liposuction alone can not remove all of the silicone oil material. There is no surgical treatment that can accomplish complete removal. Fat injections add healthy cells and improve vascularity of the treated site to reduce scarring and buttock contour deformities. It has been shown that the combination of both treatments work best for silicone granulomas of the buttocks.

I would need to see some pictures of your buttocks to get an idea as to the size and location of the problematic buttock areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering what aesthetic procedures can be done to push the lower lip forward slightly and improve the aesthetics of the labiomental sulcus? I was reading one of your case studies where a man got implants put in in his upper lip, lower lip and labiomental fold. So I was wondering whether a Permalip implant could be placed in the lower lip to give it some more horizontal projection? My lower lip is slightly setback compared to the upper but its not very significant; if this is possible what is the maximum amount of horizontal projection that can be achieved? I only need around 4mm at most. That said I have a very slight overbite where my upper teeth cover around 85% of my lower when biting down. Do you think orthodontics to correct my bite, combined with a Permalip implant could do the trick for a lower lip that is set back roughly 5mm and the above circumstances are taken into account? If I jut my lower jaw forward to the optimal bite position), my lips line up roughly accurately. But I don’t want to go through with lower jaw surgery for such a minor discrepancy. 

Also, my concern is that if I push the lower lip forward, my labiomental sulcus and chin will look too set back in comparison. The chin is fine as I am happy to get an implant placed there. More importantly, I am concerned about how the labiomental groove will appear in two ways. First, the chin advancement will make the groove look more set back. Second, if you think about it on a profile view, the lower lip advancement will pull the tissue forward and make the angle between the border of the lower lip and the middle of the sulcus more acute. My sulcus isn’t very deep, but I would like to have an implant placed there and possibly fillers or fat grafting over the top at the same time. If a custom implant is used can the labiomental augmentation be almost unlimited? 

As a side question, is it possible to give the illusion of a higher or more vertically short labiomental sulcus by strategic augmentation in the lower part of the sulcus, or through any other techniques?

A: In answer to your labiomental sulcus surgery questions, let me first make the following general statements:

1. The true position of the lower lip is controlled by the position of the teeth. Thus the single most effective method of increasing the horizontal position of the lower lip is by lower jaw advancement. Understandable that is a lot of effort to obtain that relatively small amount of aesthetic change.
2. Manipulation of the labiomental sulcus is not easily done and any such manuevers do not always produce predictable outcomes. It is a tight tissue area which has limited potential for change in its depth. This is a fixed tissue area for which there is a reason that an indentation exists there.

In answer to your specific labiomental sulcus surgery questions:

1. A Permalip implant provide some horizontal increase in the lower lip but probably not as  much as 4mms.
2. I would find it hard to imagine that even a 4mm horizontal lower lip increase would make either the labiomental sulcus and particularly the chin look recessive.
3. You are overestimating/over thinking the effect of the lower lip on the labiomental sulcus. The effects just aren’t that simple or as profound as you are believing them to be.
4. You can not change the vertical height of the labiomental sulcus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial liposuction.  I just had a revision mini facelift with fat transfer to nasal folds and high cheeks and Neck lipo. I’m unhappy with the appearance of the corners of my mouth. They have a downward slant which is extremely visible and I believe this started when I began to get fat transfer to my face to correct acne scars and facial hollow. Well after gaining weight my face gained double and my mouth is now turned downward. Please left me know if liposuction is the answer to my facial problem?

A: Without seeing pictures of your face I can not give a very informed answer. But conceptually fat removal in the face through liposuction is not going to raise up the corners of your mouth. Downward slanting mouth corners are difficult problems that do not usually respond well to lifts and increased facial volume. Many of them have to be treated directly through corner of the mouth lifts.

While it may seem like the addition of volume to your face through fat transfer was the source of this problem, and it may very well be, I can not say with any assurance that the reverse would be effective. Some fat removal by facial liposuction can be done but whether ti would be enough to change this mouth feature can not be predicted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orthognathic surgery ten years ago to correct a class II malocclusion. I had  a LeFort I osteotomy, sagittal split mandibular osteotomies and a sliding genioplasty. I am very happy with my bite. My teeth meet and my quality of life has been greatly improved. There are a few things that I am unhappy about that have gotten worse as I have aged and my face is getting thinner. The deep mentolabial sulcus I have that makes me look like I have a tiny stuck on chin, my high angle jaws, and my super long philtrum. I’d love to resolve all three of these issues but, if I were to pick the most important to me they would be my chin and my long philtrum. I am not looking to transform into a new person. I want to continue looking like myself but, with some improvement. 

Please tell me if I am off base with my assessment of my deficiencies. I’d love to have your professional opinion.

A: I would agree completely with your assessment from the concerns of a deep labiomental sulcus, the long philtrum and the high jaw angles.

Your chin shows a classic long-term sliding genioplasty outcome in which the labiomental sulcus has gotten deeper in the step of the bone cut. This can be improved by a dual approach of placing a labiomental implant on the bone and possible fat grafting at a more superficial level. (although filling in the step of the bone usually suffices) The long philtrum can be treated by either a subnasal lip lift or a more complete upper lip vermilion advancement. That choice depends on how you want to see the lip change. The high jaw angles can be treated by small vertical jaw angle implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to you because you seem to be the de facto expert when it comes to brow ridge augmentation. This will be a rather lengthy and complicated post, and I do hope to be able to get your expert advice.

Basically, I had fat grafting done to my brow ridge 3 years ago, but the issue is that the end result was asymmetric brow ridges (my right brow has slightly more remaining fat than the left). Not only that, the central brow region (radix/glabella) was not augmented enough. As a result of this, I sought a more permanent way to augment my brow ridges, and I had a PMMA forehead/brow ridge implant placed earlier this year. While this did give me more pronounced brows and fixed the issue slightly, it still hasn’t solved some of the contouring issues caused by the fat graft.

I have since been getting fillers to correct the defect, but it is cost prohibitive and I’m not a fan of getting repeated injections to this region due to the small but catastrophic risk involved.

Anyway, I’ve been researching custom brow ridge implants, and I have a few questions:

1) I understand that they are customized to fit on the underlying bone. Would having an existing PMMA implant be an issue?

2) Could the outer side of the implant (the side that gives the soft tissue push) be customized to accommodate for the previous fat graft? Again, would the PMMA implant interfere with this design process?

3) The one area that the PMMA implant did not augment were the sides of my forehead and I was told that it is because PMMA can not be placed too far out near the temples. Hence, could a silicone implant extend to the temples to create a wider and more ‘rectangular’ forehead?

I’m sorry for the trouble, and I’m sincerely hoping that you will be able to help me.

Thank you!

A: Thank you for your inquiry. The fundamental question you are asking is whether a custom silicone brow bone/forehead implant can be placed on top of the existing PMMA implant and whether such a brow bone implant can extend up onto the forehead and out past the anterior temporal lines onto the temporalis fascia. The simple answer is yes to both questions. My only additional insight is why bother to make a custom implant to fit in top of the existing PMMA implant. if you are going to make the effort to make a custom brow bone-forehead implant, you may as well remove the PMMS and make the entire augmentation out of one implant material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I was wondering whether you agree with my assessment that my philtrum (distance between bottom of nose and upper lip) is a bit too long for the best aesthetic outcome? I’ve been thinking about this because I feel like it throws off my facial proportions a bit. The thing is I don’t feel like a lip lift would suit me because it would make my lips look very downswung, as if they are frowning, and would create a very feminine Cupid’s bow appearance. I was thinking about mabye moving the entire base of the nose (including the nostrils) downwards one or two millimetres to make up for it that way? My nose is quite short and I think it would benefit my overall proportions to have this done. I’m not sure how possible it is though? Im sure it’s very rare but I doubt if it is impossible to do with a satisfying aesthetic outcome?

A:I would not disagree with your assessment of a long upper lip. It is possible, and I have done so, to bring the nostrils down a few millimeters. Otherwise known as nostril lowering. It is an infrequently requested and done procedure but that does not mean it can not be satisfactorily done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, i have a few questions about my mouth. The width of my mouth is extremely short it is about the size of my nose i have been thinking of getting a surgery to fix this issue. Before i go on with the surgery i have a couple of question that i want to know. First question is i have read online about this surgery as much as i could and almost everywhere they have told me that this is not a cosmetic surgery as it can leave scars so my question is how bad are the scars and am I able to reduce it with laser? My second question is how much can the surgery widen my mouth i have measured my mouth and it is approximately 4cm and when i look at other people their mouths can be measured up to 5 or 6cms. Now my question is how much can you widen my mouth with this procedure. i want my mouth at least like the pic i have provided. if you could respond as soon as you can that would be great so I can make my decision.

A: While mouth widening can be done here are tradeoffs of scars for it. Generally they are fairly acceptable when the mouth width increase is small. (5mms or less) But larger increases are associated with increased scarring and the need for scar revisional procedures. Given your mouth widening goals I would say this is not a procedure for you.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Over one year ago I had a facelift and damage occurred in both great auricular nerves. My ears have been horrible since then. I have trouble sleeping on them and I am aware of the pain on most days. Do you do a repair on the nerves? I would like to see if the nerves can be repaired through surgery.  I am in great discomfort all of the time.

A: What you have is a greater auricular nerve injury from your facelift that is likely due to a complete transection and the proximal end of the nerve now has a neuroma. With this nerve condition there are two nerve treatment options. 

1) Resection of the neuroma and place the nerve end into the muscle or wrap it in a fat graft. This would be the most common treatment approach.

2) Actual repair or nerve grafting to reconnect the two ends of the nerve. This is less common as finding the distal cut end of the nerve can be very difficult or impossible in the scar tissue. If both ends are found a small nerve graft may be needed if they can not be stretched and brought together.

Given your degree of symptoms it is clear that something needs to be done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had forehead/brow ridge and cheek implants placed a year ago with satisfactory results. I am looking for a surgeon for injectable fillers. While I am mostly happy with the implants, I’m hoping to get some fillers to ‘top up’ the aesthetic results.Anyway, I’m hoping to have the fillers injected to 3 areas – the cheeks, the radix and gabella/supero-medial orbital rims and the deep pyriform aperture space. My questions are:

1) Would it be safe to inject fillers over my implants?

2) What fillers would you recommend for these regions? I’m leaning towards Voluma or Radiesse since they seem to be the longer lasting fillers with good soft tissue push.

3) Specifically, would Radiesse be safe to inject over the implants since they’re supposedly injected quite deep?

Thank you for taking the time to answer my queries.

A: In answer to your facial injectable filler questions:

1. It is safe to inject fillers over the implants. The operative word being ‘over’ and not into the implant capsules.
2. I would recommend Volume since you don’t want to be deep and this has the last chance of being lumpy or irregular which is a known issue with Radiesse and why it is recommended to be injected down at the bone level if possible.
3. as per #2

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in injectable filler stop build up my brows and glabellar areas. My only concern is the risk of blindness when injecting the filler into the radix/glabella region. A few questions:

1) Would using a micro-cannula help mitigate these risks? 

2) Would using a thinner filler like Restylane be recommended, or is Voluma just as safe?

3) Could a small amount of botox help lift the ‘inner’ eyebrows so that they appear straighter? I’ve read that combining botox and fillers in this region helps the fillers last longer – is this true?

4) Finally, how many syringes of Voluma total for my cheeks and radix/glabella is needed?

Thank you for your time!

A: Injectable fillers for brow augmentation can be vert effective even if it is not permanent. I would recommend Volume to get the longest lasting effect. In answer to your questions:

I have used microcannulas exclusively for years to do all injectable fillers treatments. They not only reduce the risk of intravascular injection but also decrease/eliminatent the risk of bruising and make the procedure much more comfortable.
Voluma with a microcannula technique would be safe for brow injections.
Eliminating the muscle action from the brow muscles using Botox can only help the persistence of the filler.
I would recommend 3 syringes of Volume for the brow and cheek areas.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a male with two enlarged bony frontal sinus and recessed forehead above it, creating a dramatic big V above my mid brow. When I was younger I would grow my hair to cover it, but now that my hairline has receded, I can no longer hide these horrible forehead bumps and lines. While I’d like to get it burred and smoothed, I am horrified of the thought of a huge hairline scar. My forehead slopes back quite a lot and I would like to know if a custom forehead implant can be inserted to cover it with minimal scarring. Please find photos of the my face. The sinus bumps can be seen clearly in these, creating a V shape depression toward my widows peak. It is really obvious when I am thinner and when the sun casts shadows across my face. Because they are so close to the centre of my forehead, that they tend to make my forehead look narrow and my face thinner and longer when viewed front on and make it look like I’m always frowning unless I raise both my eyebrows. I have considered many options including fat grafting, fillers, botox, implants and of course full forehead recontouring. When I am overweight, the extra layer of fat in my face tends to make them a little less obvious, but at the moment I am very thin and they are always visible.

A: Thank you for sending all of your pictures. You do not really have brow bone protrusion and your brow position is actually good for a man. What you have is a central forehead indentation/recession which makes you think you brow bones are bigger than they really are. I have seen and treated such cases just like yours before. The best and most effective mechanism is to make a custom central forehead implant that fits right into the depressed area. I have attached a custom forehead implant design from a near identical case like yours. (yours would be more V-shaped) This is slipped in through a small incision just behind the hairline. It is the best approach because it is permanent and is custom made to augment the exact area of deficiency. This is a very straightforward procedure to do with very minimal recovery. The key is in the implant design which is made from a 3D CT scan of your forehead.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I am interested in facial reshaping of multiple areas. I have some questions:

1)  Ideally which order should the following operations be done? 

– genioplasty 

– custom jaw implants 

– rhinoplasty 

– custom midface implant 

– brow bone/forehead implant (mimic deep set eyes with lower brow) 

2) Also state which procedures can be done at the same sitting? 

3) With the custom midface implant, does it obviate the need for paranasal implants, infra-orbital rims etc 

4) Do you do sliding genioplasty? If so do you “deglove” or not while doing genioplasty?

A: In answer to your facial reshaping questions:

1. All of these facial procedures could be done at the same time. But if you were to stage them, and I would advise one to do so, then they could be grouped into two operations. (Group I = Genioplasty/Jaw Angle Implants/Rhinoplasty and Group II = Forehead/Brow Bone/Midface) Group II should be done first and they will have some influence on the rhinoplasty both at the radix and nasal base levels.
2. A custom midface implant covers the entire midface so it includes the paranasal and infraorbital rim areas.
3. I do perform genioplasty surgery. (chin osteotomies) In doing the procedure I strive to main as much periosteal/soft tissue  attachments as is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I am interested in a custom jawline implant that extends the entire vertical length of the jawline. I wanted to know if I would be a good candidate without orthographic surgery. I just want more vertical length and do you do any kind of computer generated simulations of expected results.  Also can someone have sliding genioplasty along with an implant like a wraparound to add length all the way around the jaw?? Thanks

A: If you want length along the entire jawline, it would make the most sense to do a custom jawline implant that wraps around the entire jawline. While you can have a vertical lengthening sliding genioplasty combined with custom jaw angle implants that does not make the most sense either economically or for having a smooth and continuous jawline from angle to angle. A one-piece jawline implant that crosses the chin would make for the smoothest lower edge all the way around from jaw angle to jaw angle.

You probably don’t need as much vertical length as you think. A 5 to 6mm vertical lengthening of the entire jawline can create an effect much greater than you would think. It is because it covers such a large surface area of the jaw.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you offer tear trough implant via transconjunctival approach? If so do you still use a screw to anchor the implant? I had both lower eye lid blepharoplasty via transconjunctival approach in 2010. Now I have a moderate amount of tear trough deformity. I am considering implant not filler. Is this procedure done under Local/Mac or General Anesthesia? How often is this procedure done in your office? Thank you very much.

A: Tear trough implants can be placed through a transconjunctival lower blepharoplasty approach. In most cases they can be secured with microscrews through this approach. This is a procedure that is done under general anesthesia. I have dine many tear trough implants and my new designs for these implants make it possible to more easily place them through either a transconjunctival approach or an intraoral approach which I prefer. The original and still used designs of tear trough implants were developed long ago before the use of injectable fillers made awareness of the tear trough deformity what it is today. The best design for a tear trough implant is one that wraps around the medial orbital rim as well as goes over the anterior surface of the orbital rim down onto the upper maxilla.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implant revision surgery. I had Medpor jaw angle implants put in to correct asymmetry and enhance my small jaw several years after corrective jaw surgery. After jaw surgery my plate came off on the right side and needed to be replaced and I lost some bone. The surgeon used the same size implants on both sides and was suppose to build up the back right side of the jaw with hydroxyapatite paste. This did not happen. I still have the asymmetry on the right side in the back. I overall like the implant on the left side. Can you create a custom implant to correct the deficiency on the right side without removing the original implant? Also, I really dislike my chin the orthognathic surgeon gave me as it curves up and I would like it brought down a little. The surgeon who did my Medpor implants said he could correct my chin. I decided not to pursue him since he missed correcting my asymmetry in the first place.

A: It is a valid jaw angle implant revision concept that one could place one implant over the other in the jaw angle area. The key issue is whether a 3D CT scan will ‘see’ the Medpor material clearly enough to allow an accurate custom fit to be made. The only way to answer that question is to get a 3D CT scan. Sometimes Medpor material is not seen well or looks very fuzzy with irregular outlines.

For your sliding genioplasty it sounds like you need the sliding genioplasty to be vertically opened as it is over rotated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about the possibility of ribcage expansion surgery. Would it be possible to lengthen the bone of each rib and the clavicle in order to increase the width and overall size of the chest? In a similar to fashion to Jaw advancement surgery? Aside from cosmetic reasons I would think it could have health benefits related to increasing the space for the organs which would over time grow to fill the extra space much like when someone donates a kidney and the remaining one eventually grows to near double the size to compensate. I figured you would be a good person to ask since you are well known for performing the rib reducing surgery of Pixee Fox. 

A: Ribcage expansion is not a viable operation. You can not increase the length of the ribs or the clavicles for a variety of medical and anatomic reasons. The one most significant reason is that the ribs can not be stretched out or their length increased due to the rigid attachments to the spine in the back and the sternum in the front. It is not similar at all to that of jaw advancement surgery which operates on a freely mobile and terminal bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am interested in exploring corrective surgical measures in order to minimize a facial asymmetry. I have attached a current photograph, in addition to two x-rays taken several years ago for dental work. These illustrates the cant of the maxillia & mandible. There is also a front/back asymmetry to the cheek bones as they appear to have grown/developed differently over time. This has caused jaw pain, compounded by bruxism, and damage to my teeth in general; not to mention a life long aesthetic concern. I am interested in hearing the your interpretation, possible solutions and any other guidance that might result from this cursory review. Thank you.

A: I can appreciate your facial asymmetry which is more easily discernible in your x-rays. You have an obvious skeletal-based facial asymmetry that is easily seen in the cant of your occlusion. In treating this type of facial asymmetry, the first decision that has to be made is whether you are going to treat the fundamental cause of the problem through osteotomies/bone repositioning or whether you are going to leave the occlusion alone and  do camouflaging procedures around it. This decision influences everything that would be done and how it would be done.

In treating the fundamental problem, maxillary and mandibular osteotomies needs to be done to level out the occlusion and straighten the lower part of the face. Whether this would require orthodontic preparation or can be done with the way your occlusion is now requires more information. Once that is done then a second stage for other procedures such as rhinoplasty may be needed.

In working around the existing occlusion and its cant, the longer or shorter side of the lower jaw needs to be changed. (whether the long side needs to be shortened or the short side lengthened remains to be determined) This would be combined with a rhinoplasty and other facial asymmetry procedures that may be deemed helpful.

As you can see the two choices are radically different and what you want to do with your occlusion is the key decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have attached a before and after computer morph of my desired rhinoplasty changes. I understand that the aim is very ambitious, my question is whether what this change is possible. I would like the following done:

1) Flattening of the dorsal hump and increasing the nasofrontal angle,

2) Decreasing tip projection slightly and dropping nasal tip slightly to prevent nose being too upturned after,

3) Lowering the caudal border of the columella using cartilage grafts and in doing so lower the ‘point of subnasale’ in order to achieve two aesthetics effects: a) Reducing the ‘hooked’ appearance of the nose which is caused by a curved contour of the base of the nose from a profile view and b) Reducing the upper lip length (my upper lip length throws off my entire facial proportions and makes my chin look too short) Would this need to be combined with alar base lowering so that the subnasale isn’t unnaturally low compared to the nostril bases?

4) Nostril reshaping in two components: a) shortening the nostril length in the sagittal plane and b) lowering alar rim using alar rim graft to compensate for the vertical columellar increase and to improve the natural alar rim retraction that I have.

Are all these things conceivably achievable? And if they are, can they all performed in the same procedure?

A: Let me discuss your rhinoplasty objectives as follows:

1. Eliminating the dorsal hump, smoothing the dorsal line and deepening the nasofrontal angle can be done. The most challenging of these is deepening of the nasofronal angle.
2. Decreasing tip projection by dome resection and lowering the nasal tip by cartilage grafts can be done.
3. While the columellar border can be lowered by cartilage grafts, it will not reduce upper lip length. Such upper lip length reduction can only be done by a subnasal lip lift which must be done as a separate procedure from an open rhinoplasty.
4. While alar rim grafting can improve alar rim retraction, I know of no procedure that can shorten the front to back length of the nostrils.

Performing all of the maneuvers described in a single rhinoplasty procedure is common.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Medpor chin implant removal. I had a Medpor chin implant placed over 10 years ago and I really hate it. It is too big and is not in line (literally) with my overall facial features. Moreover, the implant is visible when I smile. While my profile looks pretty good, the look of my face from the front is what bothers me. I would probably prefer to have the implant removed without another implant being placed. Would that be possible without serious droopiness of chin tissue? The chin implant used was the smallest one available and it has been carved down already. It has been fixated with 2 screws. Question for you (since I have read on the internet that you are experienced in successfully removing medpor implants) is whether or not you consider this procedure to be possible in my case and if you are willing to help?Would you require a CT scan of my jaw prior to surgery? Thank you so much for your time and I hope that you are willing to answer my questions and hopefully help out.

A: Thank your for your inquiry about Medpor chin implant removal. I have removed many Medpor facial implants including Medpor chin implants. The key question is not whether it can be removed but whether any other management should be done to the chin given the expansion of the soft tissue pad. While it may have been a small Medpor chin implant , these implants are still relatively large. Thus its removal poses a very real risk of chin ptosis. This leaves you with three treatment options:

Simply remove the chin implant and see what happens.

Remove the Medpor chin implant and replace with with a smaller and much more narrow chin implant.

Remove the implant and perform either a mentalis muscle resuspension (if it was initially done intraorally) or a submental tuck. (if performed from below through a submental incision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, How can somebody surgically achieve the male model browbone look? When it comes to this type of brow ridge, it seems like it’s not the protrusion but also the low position that gives an aesthetic and masculine “vibe” to the eyebrows. You can see the effect I’m trying to achieve by looking at the photo below 

Is the male model brow look achievable through a specific type of implant? I’ve read online that it’s more because of the rectangular shape of the orbital rim. If that is correct, could the orbital rim be reshaped for that matter, namely for purely aesthetic concerns?

A: You are correct in that lowering of the superior orbital rim is just as important as  any amount of horizontal projection increase to achieve a stronger male model brow look. This can only be done using a custom brow bone implant design made off of the patient’s 3D CT scan and then inserted through an endoscopic approach.

The key dimension in this brow bone implant design is that it must sit as low as possible on the brow bone on the inferior edge. This requires a periosteal/periorbital release across the brow bones similar to that used in an endoscopic browlift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting Restylane fillers to improve the appearance of the bags under my eyes. But, I am not entirely certain if Restylane or other injectable fillers are suitable. In looking at my pictures do you believe that Restylane could be a solution? Thank you!

A: I do not believe that injectable fillers under your eyes are a good treatment. While the objective may be noble to try and smooth out the undereye area, what will occur instead is the creation of large balloonish lower eyelid bags making the entire situation worse. I have seen this too many times. The effective treatment is a lower blepharoplasty to partially remove some of the herniated fat pads and reposition other parts of the fat over the infraorbital rim.

While injectable fillers have a role in correcting undereye hollows, they do not work well to help camouflage bags in my experience. Placing injectable fullers around the bags will usually lead to creating ‘filler bags’ with the whole undereye area looking fuller or bloated. While such filler can be removed by hyaluronidase enzymatic digestion, it is usually best to avoid this problem in the first place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a successful Medpor square chin implant put in three months ago. It gave my face better balance and a much more masculine look although my chin was not that small before the surgery. I have quite a defined jaw but not a square and as sharp/symmetric and balanced as I would wish. My plastic surgeon here does not do jaw angle implants so I am considering flying in to you. Can jaw angle implants make good definition without making the face look that much bigger?

A: What you are likely referring to is a vertical lengthening jaw angle implants that provides sharper jaw angle definition but does not add much width to the jaw angle. This is what I call the jaw angle defining implant and is uniquely different than the standard widening jaw angle implant which has been around for two decades. By today’s aesthetic standards this traditional jaw angle implant style is poorly designed and does not work well for most patients. It often creates a jaw angle is wider and rounder (fatter) but not more sharply defined. This is why I designed the vertical lengthening jaw angle implant style as that is what most men and women are seeking today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a pediatric cranioplasty for my young sone. You stated that bone cement would be the best option for a younger patient. Why is this the preferred choice instead of an implant? If we did this for our son would he have any issues in the future? For example- could he play football and would physical roughness or a tumble off his bike, or any other mild head injury pose a health risk with the bone cement? Also you stated that we would have to go thru insurance with a predetermined level of approval. This could be difficult considering the doctors we have spoken to consider this to be a cosmetic issue. Could it be something we electively do for our son? I am just devastated that we blindly trusted his doctors and did not helmet him! I am heartbroken that my lack of action has left his head deformed. I know you can’t give an estimate without a proper consultation but I am serious and intend to be very aggressive about this before it could possibly effect my sons esteem and quality of life so could you give even a rough or general estimate so that I know where my family needs to be financially to even consider seeing you?

Thanks again for your time!

A: In young children with growing skulls, the use of hydroxyapatite cement seems the most biologically appropriate for a pediatric cranioplasty as the cement will integrate into the bone. (bone will actually grow over it and it will become incorporated into the bone as it grows) Thus both short and long-term there would be differences in the skull’s growth nor affect its structural integrity. A custom made skull implant in many ways is ‘simpler’ because it is reshaped this makes the surgery easier. But the long-term fate of such an implant on the skull’s growth is unknown as it has never been done to my knowledge. Whether it would affect the skull’s growth or would in any way affect the function of the skull bone is unknown. It may well be that it does not but there is no way to predict that up front.

Because of the cost of hydroxypatite cement, the need for a pediatric anesthesiologist and its performance in a hospital (in adults I simply do this in my surgery center), the cost of such surgery would be astronomically high and out of the economic reach of most families. For this reason every effort should be made to go through the insurance predetermination process. With insurance submission you never know what they will or will not approve. I have seen such cases go both ways. (approved vs. denied)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I intend to make the brow bone augmentation , but I have doubts as to what material you prefer. I want to know if there is the possibility of having contact with patients of this type of procedure? I’m curious to see how the result was , as the photos that are on this site do not show at various angles. Thanks.

A: When it comes to brow bone augmentation the type of material used is largely irrelevant per se. What matters is the surgical approach (open scalp incision vs endoscopic), amount and shape of the desired brow bone augmentation, cost and the risk of revision. All of these factors put together will ‘control’ the material of choice. I have used every material for brow bone and forehead augmentation that exists and they all can work in the right circumstances. Each material option has their own advantages or disadvantages, none are perfect. The material chosen does not control the shape or the result, just how easy or hard it is to achieve it.

Young facial reshaping patients are notoriously discreet about their surgery and few will allow their pictures to be shown or will talk about it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking into your procedure for fat grafting for Coccydynia. I have pain around my coccyx and sitting down is painful for me. I’m looking for a pain relief alternative to having the coccyx removed. I wanted to know exactly how the procedure is done.

A: There are two methods fat grafting to cover the coccyx with the intent of providing increased padding over the bone. The first method is dermal-fat grafting. There is where a strip of skin and fat is taken (usually from the abdomen) and implanted over the coccygeal bone through a small incision. (dermal-fat grafting) The second method is injectable fat grafting where fat is harvested by liposuction, processed and then injected into and around the ccocygeal bone. The success of both methods would be based on how well the fat survives. I have done both numerous times and there are advantages and disadvantages with each method. Dermal-fat grafts usually survive better but require a harvest site and an open incision to place. Injectable fat grafting is incision-free but its survival over the pressure point of the coccygeal bone, which is also frequently sit on, is less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve also been looking into custom jaw implants to add some vertical length to my ramus and chin. However I’ve noticed that in the vast majority of these cases the results tend to look unnatural and often times asymmetric. Whilst I was confused about seeing the asymmetry in several of these custom implants (surely the designing process would have attempted to avoid any asymmetry?), this is less of a concern for me as some of the results I have seen are symmetric and thus I think with the right planning that can be avoided. However, what is bugging me is the synthetic ‘afters’ of most of these custom jaw implants. I don’t know how to describe it other than that it sometimes looks very ‘plastic’ which of course it is. Also I’ve noticed that a lot of these cases look very ‘bloated’, almost as if they have bruxism caused masseter hypertrophy. But why do the silicone implants create this unnatural looking effect through soft tissue? Even where augmentation isn’t extreme, the really sharp mandibular border that the implant creates doesn’t seem to look real. Is there anything to be said here about eliminating this effect?

A: Jaw angle asymmetry is the norm in jaw angle implant surgery not the exception. Whether the degree of asymmetry is significant or bothersome to the patient will vary widely. I have seen patients with small amounts of asymmetry have multiple surgeries to try and make it perfect while other patients with larger amounts of asymmetry are perfectly content with it. My experience is that if you are a young male you will fall into the former category and will not rest unless it is near perfect. While making custom jaw angle implants definitely helps decrease the risk of postoperative asymmetry, it does eliminate it completely. There is the implants design and then there is the actual placing the implant. I have an enormous experience with jaw angle implants and even I have a 10% to 20% risk of jaw angle asymmetry particularly when it comes to implants that create any vertical lengthening of the jaw angle.

Most people that seek jaw angle enhancement need vertical lengthening and not just width. All current commercially available jaw angle implants create width only and are inadequately designed in my experience. But that is what is available to almost all surgeons so that is what gets used. This wide rounded angle implant creates a fatter jaw angle not a more defined one in most cases. I am to sure what you refer to as ‘really sharp jaw angle implants’ since no such style of jaw angle implant is currently available to my knowledge. I have my own line of vertical jaw angle implants and often will custom design them to get a sharper  and not rounded jaw angle look. That begin said, not every face can end up with a more defined jawline look. The heavy the face or the one with thicker tissues will never get a very defined jawline/jaw angle effect from any type implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Permalip implant removal. I had 4mm Permalip implants put in my upper and lower lips this past year. It has not even been a year but I would like to get the upper implant removed. It causes a crease when I smile and my smile looks restricted and very unnatural. I have been doing a lot of research and you seem to have quite a bit of experience with the Permalip implant.

I had a few questions:

1.) how long would my upper lip be swollen for/how long would it be noticeable.

2.) how quickly could I start again with filler

3.) Will my smile go back to normal or will it stay restricted from the lower implant still being in?

4.) what is the cost of the removal of the upper implant only?

5.) Have you removed quite a few implants and are there ever complications?

Thank you!

A: In regards to Permalip implant removal:

1. There should be very minimal swelling…unlike the original placement.
2. You may return to getting injectable fillers 6 weeks after the implant is removed.
3. I would anticipate that your smile will return to normal. This is a mechanical obstruction issue.
4. My assistant will pass along the cost of the procedure to you tomorrow.
5. Once the implant is removed I have yet to see any complications that have resulted…other than the lip will become smaller.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation. I have a depression on the back of my skull which has bothered me for numerous years. I have had it since birth so it has not been caused by an accident. I would be interested in injecting PMMA to fill the area or inserting an implant, however, I am worried about the side effects, especially since it is not a common procedure. I have long hair, will the incision cause a bald spot on my hair line? Is there anyway to make another incision which does not affect the hair? Is PMMA safe or could my body reject the substance? Would an implant stay in place with only soft tissue holding it in place? Is this procedure possible under local anesthesia? The reason I ask is I have a surgery planned for August under general anesthesia, and I am told general anesthesia sessions must be spaced 6 months apart, however I would like this surgery sooner than that. Thank you for your time.

A: Filling in flat spots on the back of the head (skull augmentation) is one of the most common of all aesthetic skull reshaping surgeries. It can be done successfully by either bone cements or implants based on the size of the defect and patient preference. Most patients opt for either custom or semi-custom silicone implants because of their ease of insertion, smaller placement incisions and lower risk of palpable implant edge transitions. The body does not reject such implants although there is a very low risk of infection. The implanted materials doe not affect overlying hair growth. Any potential hair growth alterations lie along the incision line. These type of skull augmentation procedures are best done under general anesthesia not local anesthesia. I am not aware of any medical validity to the need to space a general anesthetic six months or any number of months apart.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip reduction. I had persistent dryness and swelling on my lower lip. A biopsy was performed the report of which is below. Since considerable amount of tissue was removed during biopsy my symptoms have improved somewhat. However the problem is still not resolved completely. My lower lip is still very bulky. So I am thinking if a lip reduction surgery or vermillionectomy of the lower lip would help me.

A: Thank you for sending your pictures and describing your lip symptoms. A lower lip reduction can definitely help the symptoms of cheilitis by removing the abnormal mucosal tissue. The degree of symptom improvement is based on how much of the abnormal (dried) mucosa that can be removed without creating any significant lip distortion.

I would think subtotal lip reduction first before considering a total vermilionectomy which will cause some lower lip color distortions. A vermiollionectomy can always be performed secondarily of the lip reduction does not provide significant symptom improvement.

Reducing the lower lip is often performed under local anesthesia. Resorbable sutures are used to close the incision which take a few weeks to dissolve or fall out on their own.

Dr. Barry Eppley

Indianapolis, Indiana