Your Questions
Your Questions
Q: Dr. Eppley, Thank you for your amazing job you do as a surgeon and to inform all the patients online. I know (as read on your site) custom implants would be my best choice. However, i really do not want implants, there’s a 0% chance of me getting implants. A friend of mine had a “zygomatic osteotomy” and a “chin wing osteotomy” and I think his results were very good. Do you perform these surgeries? Do you use some bone grafts? Why would you, or why wouldn’t you recommend the following procedures’?
A: When one tries to compare different facial reshaping operations it is important to carefully investigate up front what dimensional changes they can actually make. I have perform many zygomatic osteotomies (for cheekbone narrowing and cheekbone widening) as well as the chin wing osteotomy. The zygomatic osteotomy provides width and width only to the zygomatic arch and the very posterior aspect of the zygomatic body. It can not provide any anterior projection to the cheek as that is not the direction that the bone moves. The interpositional gap created by the zygomatic expansion osteotomy can be grafted by bone or an hydroxyapatite block. The chin wing osteotomy is useful for two types of jawline changes. It is primarily useful in creating a sliding genioplasty effect where the entire jawline is moved as the chin comes forward and downward. It can also be used to vertically lengthen the entire jawline.
The only reason I ever do these types of facial osteotomies is when the patient wants to do a ‘natural’ operation as opposed to the use of custom facial implants for a very specific type of facial dimensional change as outlined above.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. I have very deep set eyes, protruding forehead with brow bossing. I look like I’m mad and my eyes are hooded by bone. My forehead slopes downward from orbital rim a little and brow is very low set. Also I have calcium deposits on the front and sides of my head. I wouldn’t mind something dramatic but just doing some shaving on forehead and brow in front, possible slight brow lift would do wonders. I want to open up my face. I want to project what I feel on the inside and when I go out side I don’t want to see my brow especially when I squint which I’m usually forced to do.
A: Than you for sending your pictures. You do have prominent brow bones and you are correct in what their effect is on your eyes/face. I would agree that a brow bone reduction and forehead shaving and a brow lift would be very beneficial. Like in any man, however, the key issue is the surgical access to do so. This is always problematic in men where the use of a coronal scalp incision creates its own aesthetic trade-off. Usually in men because of their hairline location and hair density, the better option may be a mid-forehead incision in a horizontal wrinkle line. This eliminates the ability to do an overall forehead bony reduction. But an endoscopic browlift can still be done through very limited scalp incisions at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a LeFort 1 osteotomy done two years ago and I’m looking for a revision as it was done poorly. For the first surgery, I only had rubber bands and was allowed to remove them after the first week for meals. (soft food) However, I’ve read of many cases whereby the patient is completely wired shut for weeks. Why do some patients have such strict fixation while others don’t? Would not getting wired shut lead to a greater chance of relapse or a poorer outcome?
A: Historically, LeFort 1 osteotomies were done using wire bone fixation and the need to use maxillomandibular fixation (jaws wired together) to hold the bone in place as it heals. Since the late 1980s and early 1990s, LeFort osteotomies have been held into place using plates and screws thus obviating the need for wiring the jaws shut after surgery for six weeks to allow the bones to heal.
While I have no idea what type of bony movements were done with your LeFort 1 osteotomy, your after care with temporary rubber bands suggest that you had plate and screw fixation. If properly done the use of plate and screw fixation would create a comparative result to wiring the jaws shut for six weeks. In theory long-term stability would be improved with the plate and screw fixation technique. The risk of a malaligned bite after a LeFort 1 osteotomy with the jaws wired shut for six weeks, as uncomfortable and historic as that is, has a lower risk than that if rigid plate and screws fixation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get cheek implants, a sliding genioplasty and jaw angle reduction.My question is that I have just had maxilla advancement jaw surgery (LeFort 1 osteotomy) one months ago. Only the maxilla was moved forward. The mandible was not moved. How long is necessary to wait before I can come see you to get these surgery procedures done? I worry the maxilla may be banged in the surgery or after 4 weeks is this not a problem?
A: Since you just had a LeFort 1 osteotomy just four weeks ago, I would wait a full 8 weeks before doing any surgery that would involve re-entering the surgical site (cheek implants) This is not because the maxilla has any change to be displaced. (it is undoubtably rigidly secured into place with plates and screws) but because you want all the swelling to get out of the cheeks so you have a good idea when placing cheek implants so that the style and size of the implants could be best judged. As it relates to the mandibular procedures (sliding genioplasty and jaw angle reduction) the previous LeFort 1 osteotomy has no impact on their execution and vice versa. But waiting until all facial swelling has resolved is still worthy of the wait.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a large chin button and excess soft tissue padding as well. My oral surgeon plans to slid the chin button (sliding genioplasty) during a jaw surgery but can you reduce the soft tissue afterward? Does this sound reasonable?
A: In interpreting your question, I assume you are having a sliding genioplasty done with a sagittal split mandibular advancement osteotomies. Having a large chin button implies that there is a bony knob on the end of the chin. Onto which you are saying there is a large soft tissue chin pad on top of this chin button. Your question then implies there may be an excessive soft tissue prominence of the chin after the sliding genioplasty is done and whether this can be reduced secondarily. While I would think it can that is a statement made without any knowledge of what your chin looks like or what the lateral cephalometric x-ray shows before the surgery. (how thick does the soft tissue chin pad appear) While this would be an unusual sequence of chin procedures (sliding genioplasty followed by secondary soft tissue chin reduction), for now let us assume it is appropriate to be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom jawline implant placed six weeks ago. I can open my mouth fully and the swelling was pretty much gone around the 3 week mark. (As in, it was difficult to notice any further reduction in swelling.) There’s no numbness in the lip or the skin around the jaw.The implant looks pretty great, too. I would have benefited from a larger implant, but I am happy with the results in that it is still a significant cosmetic improvement.
Only one question: The tissue right at the angle of the mandible on the right side is sensitive to pressure. That is, if I press on it or the outer side I feel a dull ache. Sort of like a pressure point. I notice this when sleeping on my right side since the pressure on the jaw from the pillow can make it uncomfortable. It can vary in sensitivity depending on how often I try to sleep on that side (i.e. longer periods of pressure = more discomfort when reapplying pressure). I am wondering if this is might be, like abnormal sensory nerve regrowth or a ligament with a small tear. This issue has been present since I was able to start sleeping on my side after the surgery.
A: Every implant that involves the jaw angle has to elevate the masseter muscle off of the bone. This is particularly relevant in a custom jawline implant. Thus everyone sustains a large muscle ‘tear’ so to speak. There are no nerves or ligaments in the jaw angle area. Like many muscle injuries it can take up to three months to have full healing. Why one side would feel good and the other one is still sore is not rare and actually occurs most of the time. Bilateral surgeries never heal exactly at the same rate. I have no cause for concern at this still early point after surgery although it probably doesn’t feel that early to you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 46 year old male. I was born with a high and wide forehead. I noticed some hair loss/thinning beginning about 15 years ago. I had a strip hair transplant surgery at that time with approximately 1,000 grafts. I used Propecia/Rogaine for years after the procedure with no change. I have been off those hair regrowth medications for years now with no change. I underwent an FUE hair transplant procedure last year of around another 1,000 grafts to improve and lower my hairline. As you can see from the attached pictures, there has been little hair growth with pitting and my forehead remains high and wide. Attached are pictures with a drawn in hairline. The approximate distance from my natural hairs behind the FUE grafts to the central point of my envisioned hairline is approximately 3.5 to 4 cms. Do you think I am a better candidate for another hair transplant or a hairline lowering procedure?
A: A hairline lowering procedure without a first stage tissue expansion will only bring the hairline forward maybe 2.0 to 2.5 cms centrally. With the prior occipital strip harvest (where scalp tissue is lost) that may limit even that amount of hairline advancement. In addition a hairline only brings the central part of the hairline forward and moves the temporal regions less so. While you understandably find your hair transplant results underachieving, the placement of a frontal hairline scar to move the hairline forward does not seem to be a worthy tradeoff with your existing hair density. I would suggest that further efforts should be directed towards additional hair transplants for your hairline lowering efforts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in multiple facial reshaping procedures. I went to a lot of surgeons who usually said that everything was perfect and no surgery needed. But I may see things a little bit more detailed or have a different idea of beauty. Some said my chin has an asymmetry, is too pointy, has too much soft tissue on it. Some wanted to do pre jowl implants. Some said my chin is too long and wanted to shorten it. I see that my chin is too long but I don’t think it is the length that is bothering me. It is the whole jawline what makes my chin look like this. My jawline is too long and narrow and not round enough. I will send you my picture first and the second one will be one picture that I changed with a Photoshop tool and I will explain on the picture exactly what Iwanted changed. Please take your time to understand what I try to tell you.
I want to look softer instead of elegant and have a rounder fuller face. I don’t like my high cheekbones and the spot where my cheekbones end there is nothing but flat. I don’t like my eyebrows they are sticking out to the front too much instead of the eyebrow bone being more flat or far in.I don’t like that my chin sticks out too much too. Can we take it back or should we widen it? I have no Idea. Every surgeon said my nose is perfect but they maybe didnt see that when I laugh it points downwards and I personally think that for my narrow face my nose should be flatter. The tip of my nose has to go slightly up. So you see I like to have a more flat more wide face. Everything in my face sticks out too much. I hope you can understand what I mean.
A: Thank you for your inquiry. I have studied your descriptions and concerns as well as your pictures. My facial reshaping surgery responses would be as follows:
CHIN – It has too much horizontal projection. It should be set back about about 5mms by intraoral reverse sliding genioplasty
JAWLINE – It can be rounded/made wider by a custom jawline implants that extenjd from the jaw angles to just behind the chin.
NOSE – As you have well described it, the tip needs to be shortened and rotated upwards and some reduction of the radix height between the eyes.
INFRAORBITAL RIMS/CHEEKS – These should be augmented with an implant that combines the infraorbital rim and cheek area as a single implant. These would be placed through an intraoral or lower eyelid incisions.
BROW BONE – The tail of the brow bones would be flattened by bone burring through upper eyelid incisions.
All of these procedures could be performed as a single operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for getting back to me so quickly in regards to my cheek implant removals.This has been such a nightmare and I just want to let you know how appreciative I am of your time. I had small malar/submalar implants put in one year ago. In hindsight I did not need the implants. I felt the implants were sharp and didn’t go with my soft delicate features. I waited for six months and then had them removed.
Now I have a whole new set of problems. I now have stretched out skin and sagging nasiolabial folds ( I think it’s my cheek collapsed) that are making me look much older and less beautiful than I am. I have attached a photo of me before and after removal so you can see what’s going on. I am considering having implants put back into my face as one option. Please let me know if you have any thoughts and or suggestions. I read your article about cheek suspension in situations similar to mine and I am hoping you may be able to help me.
A: Thank you for sharing your story of cheek implants and subsequent cheek implant removals. The sequelae from their removal is common and makes biologic sense since the implants disinsert the bony attachments of the overlying cheek soft tissues. Once the implants are removed, the overlying cheek tissues slide downward creating the effects you now see. Given that it has been six months since your cheek implant removals, you now have a good feel of how you look and whether you can live with the tissue changes.
Improving the fallen cheeks comes down to three options; 1) put back in new cheek implants, 2 ) do fat injections instead of cheek implants or 3) perform cheek resuspension. All three cheek restoration approaches have their advantages and disadvantages. The easiest is volume restoration through either new cheek implants or fat injections. Cheek implants would be more effective than fat injections for a variety of reasons. Cheek resuspension is always more appealing as it directly treats the actual problem but it is more unpredictable and is best done through a lower eyelid incision. Given your young age and what you do professionally, I would be hesitant about any external incisions on you no matter how well they may heal. Intraoral cheek suspension avoids this external scar concern but is far more challenging to do. The Endotine cheek/midface lift is one device that helps successfully execute the cheeklift procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to have a custom facial implant procedure and am participating in its design. I would like to have an implant that creates a dramatic amount of a facial augmentation effect. My surgeons seems skiddish about such a large custom facial implant design. What do you think?
A: While I have no details about your custom facial implant design, your desires probably are coming close to making a classic custom facial implant implant design mistake. Just because it can be designed and it fits on the implant model, that doesn’t mean it will actually fit in you during surgery. Implant designing must take into consideration the soft tissue cover and how thick or thin it is. That is knowledge that the surgeon has that patients don’t. I have also learned, and more painfully so for those patients involved, that lack of consideration of the soft tissue layer can result in major complications that have led to the need to remove the implant. It is important in any custom facial implant design to not get too greedy. Reaching for the maximum implant design often leads to complications. It is far better to have an uncomplicated outcome that is 70% to 80% of the desired result than obtaining 100% of the desired result with a complication.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We have already had a very informative Skype discussion about a possible nuchal ridge skull reduction at the back of my head with occipital implant above it. I think you suggested that the scar may be in the region of 7 to 9cms in length. I spend a lot of time on your excellent website and am certainly impressed by some of the outcomes relating to skull cosmetic work. The one thing thing which is causing me trouble and keeping me awake at night is the prominence of the residual scar. I intend to have my hair very short, but not fully shaved and keep imagining a visible white line across the back of my head where hair won’t grow.
I know most of your pictures on the website can only really be taken before and immediately afterwards, but it is the medium (several weeks) and long term view (months/yrs) that I would really like to get a handle on. Would you have any images you would be able to share with me?, or alternatively, I see many men on your website who have had similar procedures in a similar context (v. short hair) – would it be possible to ask to forward my details to some of them in the hope they could provide insights into how their scars have settled down?
I accept that their will be a trade off when undertaking a procedure like this, but at the moment my view is not as informed as I would like.
A: Like all patients, particularly men, the issues of scars on the scalp is a major aesthetic concern and consideration in doing any skull reshaping procedure such as nuchal ridge skull reduction. This is particulalry paramount in men that shave their head or have very closely cropped hairstyles. Since I almost never see any patients long-term and men are particularly private about their aesthetic surgery, the information you request is not obtainable. On the positive side, the fact that I have never had a scar complaint or performed a secondary surgery just for the revision of a scalp scar speaks to the general issue that it has not been a poor aesthetic trade-off.
However, the reality of scar concerns in any surgery is that what happens in one patient or lots of other patients is no guarantee that your scalp scar may turn out just as favorable or not of a postoperative concern. Therefore, I have a simple strategy for how to approach the uncertain nature of how scars will turn out in aesthetic surgery and whether one should proceed with surgery. When there is any doubt or apprehension….don’t do it. One should only press forward when they have the attitude that however the scar turns out, its trade-off is more acceptable than the problem they currently have. When a patient tells me they are so concerned about the appearance of the residual scar that it ‘keeps them up at night’, they are not a good candidate for the surgery.
You may think that with more education about the scar, you could make a better decision. But that is actually incorrect and even misleading. One happens on on patient does not always translate to another. Scars are both trade-offs and gambles, one has to have the attitude of ‘rolling the dice’ is worth it for the other benefits of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery. I am a 44 year old transgender male to female that is struggling to obtain an hour glass figure.I have breast and buttock implants and was hoping to reduce my waist line. I run everyday and do abdominal trainings but I have the body I was born with and am trying to improve on it. It does not appear I am making much progress and I can’t get any thinner by diet and exercise.
A: What you struggling to achieve is to overcome the natural anatomic differences between the male an female ribcage. The actual number of ribs between males and females is actually the same despite the well known biblical citation …’The Lord God fashioned into a woman the rib which he had taken from the man…’ (Genesis 2:22) Both genders have 12 pairs of ribs although a few individuals have an extra rib or pair of them.
There are, however, some shape difference between them. The last pair of floating ribs in a female tend to be smaller in order to permit child bearing and is one reason women have a more narrow anatomic waistline. The other if not more important reason is that the arc or curve of the ribs in men is wider particularly in the lower half of the ribcage. This gives men a more ‘barrel effect’ of their torso and not that or a t=more tapering look as the level of the anatomic waistline.
Thus you are correct in that you are battling an anatomic difference that can not be changed by diet and exercise. You have really done all you can physically do. This is very common in transgender female and is one of my three types of patients who benefit by rib removal surgery. Removing ribs 11 and 12 combined with abdominal side wall liposuction all done from the prone position is the surgical step that will overcome this natural anatomic limitation.
Dr. Barry Eppley
Indianapolis, Indianapolis
Q: Dr. Eppley, I am interested in lip reduction surgery. My goal is to reduce to size of my lips by about 30% or a bit more. As you can see from the photos, my lower lip hangs and my upper lip goes out far. I would very much like a more even reduced lip look.
A: Thank you for sending your lip pictures. The typical reduction amount achieved in most lip reductions is in the 20% to 25% range. Sometimes it may be as much as 30% to 35%. But it is always best to think of lip reduction surgery as possibly consisting of two stages to get the ideal lip size reduction result or the best scar outcome. This is more true in very large lip reductions that I have done in many African Americans. The goal is to achieve the maximal lip reduction in one surgery but there are limits as to how much lip tissue can be removed and get the wounds closed in a single surgical event. Thus it may be necessary to ‘walk’ the lip edge backwards through two operations. One should separate the two lip reduction surgeries, if needed, by at least 3 months.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to see the possibilities of skull reshaping surgery. I am 33 years old and have always been unhappy with the shape of my head. My head is big overall and I dislike the unusual shape and so I would like to change this for it to look more normal. I have the following concerns about my head shape: (1) It slopes down and stands tall at the back side. (2) I have a protruding knob on the back. (3) it’s wide on the sides. So please look at the pictures I have attached.
A: Than you for your inquiry and sending your pictures. I can certainly see your skull shape concerns with a very convex posterior temporal region which connects with an occipital protrusion and a higher posterior sagittal region. All three of these skull areas are really connected and part of the overall skull shape protrusion. While I think there is no question some major improvements on your shape can be made by bone and muscle reduction, it will require a full coronal scalp incision to do so. In a male with your close cropped hairstyle that always give me pause. Every aesthetic surgery involves tradeoffs and one has to evaluate the scar vs. the skull shape benefits very carefully. You never want to trade into another ‘problem’ that you may dislike just as much as what it was designed to treat.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I already had orthognathic surgery several years ago which involved moving my two jaws forward. Now I’m considering that augmentation was too much and I would like to revert the procedure and move my two jaws inward and upward. I’ve already had braces for years and they are not an option anymore, in part because I already have veneers in my teeth. I hear some doctors perform this surgery without braces in cases where the bite is already correct. Would this be an option? Thanks.
A: Doing double jaw orthogathic surgery without braces is known as non-orthodontic orthognathic surgery. You are correct in that it is rarely performed and many maxillofacial surgeons will not do it. If your teeth have a good interdigitation (occlusion), and they should from prior orthodontic work, then you can have orthognathic surgery a second time without them. The key is that both jaws have to be moved together with the teeth fixed into occlusion during the operation. (using preoperatively fabricated splints or the Omnimax inter maxillary fixation system) Provided that the jaws can be moved in the desired direction (moving the maxilla back is the harder one), then the surgery can be done without the preoperative application of orthodontic brackets.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping surgery. As you are probably aware, healthcare over in the UK is pretty much free. Cosmetic surgery is not given for free due to the fact its simply cosmetic, something you don’t like the look of on your body. If it is present from birth or is causing psychological effects, it can be done for free. I have had a very flathead from birth and it is causing me all sorts of stress and depression. Do you think the NHS (National Health Service) in the UK can provide me with help? Have you heard of anyone getting this type of surgery in the UK through the NHS? Also whom would you recommend that I go to for skull rehaping surgery in the UK?
A: I have had this question from patients from the UK many times. The simple answer is that there is no surgeon in the UK or Europe that performs these types of skull rehaping surgeries. And even if there were, NHS would consider this a cosmetic surgery just like all insurers do in the U.S.. Reconstructive skull surgery is for the restoration of skull contours for partial or full thickness bone defects. Aesthetic skull reshaping are a collection of cosmetic procedures whose purpose is to change the shape or contours of a skull that have adequate bone thickness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a Brazilian Butt Lift. I am a 24 year old female who is not comfortable and is ashamed of her body. I have been doing research on Drs where I currently live and I haven’t found a Doctor who meets my expectations. And I have seen your woek and I like what you do.I think I am a perfect candidate for a Brazilian Butt Lift since I have some extra fat over my entire body gained after I had my son via c-section three years ago. I really really want a better body with an “S” shape on the sides. I want my butt and my hips enlarged and I am really hoping you are the one who can make my dream come true.
A: As you know the Brazilian Butt Lift or BBL procedure is a dual benefit operation where multiple body areas are contoured through the redistribution of fat approach. The liposuction harvest areas create reduction while the fat transfer to the buttocks causes an augmentation. While the Brazilian Butt Lift is a very common operation today, and I have done many of them, the keys to a successful and satisfying outcome are based on realistic patient expectations and an understanding of the natural biology of fat transplantation. Let me highlights these key points:
1) The liposuction harvest is not an overall body liposuction procedure. The goal is to obtain as much fat as possible for the buttock injections for which the vast majority comes from the abdomen, flanks and back areas. The reduction of the waistline above the buttocks plays a major role in helping the buttocks appear bigger.
2) There may be undesired aesthetics from the liposuction harvest in the abdominal region, particularly in women that have had chldren. (loose skin) Ay such loose or irregular skin may require a secondary tummy tuck to create the best abdominal contouring effect.
3) The size limitations of the buttock augmentation increase in BBL surgery is a direct result of how much fat one has to harvest. Thus some buttock enlargement goals are not possible for some women because there is a mismatch between what they want and what they have to give to try and achieve it.
3) The amount of fat that is available to be injected into the buttocks is but a portion of what is harvested. Since the best type of fat to inject is a concentrate of the total liposuction aspirate, not all fat volume that is extracted ends up being injected. It must be concentrated which in women usually means about 40% of what is harvested is useable for injection. (e.g., 1,000 of fat harvested = only 400cc to be injected)
4) The survival of injected fat is not predictable and is never 100%. Thus some of the injected fat will die and some of the initial volume increase will be lost over the first six weeks after surgery. This fat transplantation biology fact seems to confuse many patients as they wonder why their results are ‘disappearing’ over the first month or so after surgery.
5) The final outcome of any BBL surgery takes 6 to 12 weeks after surgery to stabilize and see the final result. But it will not end up as full as one what sees in the first weeks after surgery.
These are the important concepts to understand so that one can have a realistic expectations about what to expect from their BBL surgery results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in male brow bone reduction. But because of my hairline I can not have a coronal incision to do the procedure. I know that the alternative for some men is a mid-forehead incision. But that would only be for brow burring correct? Which wouldn’t have a very big overall impact as my bone is thin. It seems the only real option is to have coronal incision which just seems very excessive. Surely there is a better way to do it.
A: Your assumption about the limitations of the mid-forehead incision for male brow bone reduction are incorrect. Total brow bone reshaping by osteotomy and bone replacement can be done through this small mid-forehead incision….not just bone burring. (there are very male patients who would get any benefit from simple bone burring of the brow bones) I have done it many times and for smoke men it is the only way to do it because of their hairline location or density. One could also use the old open sky incision at the top of the eyebrows and across the nose but this risks permanent injury to the sensory nerves of the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a tip rhinoplasty repair. The tip of my nose went bright pink about two years ago. I have consulted with dermatologists and ear nose and throat surgeons. Until today nobody could name what is to me a problem. I came across your website and I feel so relieved as I saw a picture of someone with my same problem. The tip of the nose has split. The cartilage is in two pieces and what used to be a nice nose, to me now looks wonky. I would like to come and see you and get it fixed. I look forward very much to hearing from you.
A: Thank you for your inquiry and providing your history and picture. Your history is a bit unusual for the classic bifid nasal tip deformity as the separation of the lower alar cartilages is almost always of congenital origin. The typical bifid nasal tip patient has had it all their life because that is just the way their nose developed. To develop a nasal tip crease later in life and after the tip of the nose developed a bright pinkness suggests not a tip cartilage issue but a crease that has developed in the skin itself. (perhaps from an automimmune disorder) Regardless of the specific cause (split of cartilage or dermal skin crease), it can be successfully treated by a limited open tip rhinoplasty. It may involve tip cartilage reapproximation, overlay septal cartilage grafting or a crushed cartilage graft. That would have to be determined intraoperatively when viewing what is on the inside.
DR. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in migraine surgery. My migraine history is long. I started having migraines over twenty years ago. I take multiple prophylactic and rescue medications with mixed results. My headaches usually last two to three days and have lasted up to several weeks. The post-dromal lasts up to a week longer than that. I have had as little as a migraine every week or as many as a dozen migraines a month. I have been getting Botox for more than a year. Under normal circumstances I get a migraine a week, usually a 5-7/10 severity, taking the current medications. After the first day or two of rescue medications I stop taking them, I don’t think they do anything if they haven’t worked on the first day or so. I get Botox shots injections every three months.
A: Thank you for providing your detailed history and medication profile for your migraines. While migraines are complex, qualifying those patients that may have a successful outcome from migraine surgery is much simpler. The surgical treatment of migraines is based on identifying those migraine patients that have focal trigger points where the sensory nerves exit from the skull and pass through muscle where they can be entrapped. The three classic areas are the supraorbital, temporal, and greater occipital regions. Good surgical candidates have very specific trigger areas that they can pinpoint precisely, have repeatable symptoms from the same focal areas and usually have positive relief from Botox injections. Since you have had repeatable positive responses to Botox, it would be helpful to know more specifics about those injections. (location and dose)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline surgery. The kind of strong jaw and face I’d like to have is like his model picture that I have attached which shows how her jawline drops and she has very pronounced and positive cheeks which I really like. I want something extremely dramatic, my jawline isn’t anything like the model I showed above. I’m cute, but my face is just so narrow that it takes away from the potential attractiveness that I could have. The debate for me is either a sliding genioplasty and two hardcore flared jaw angle implants OR a custom implant for everything. I hate the side profile view right now, as my nose and philtrum are overprojected and everything else is just weirdly shaped due to my terrible genetic inheritance.
A: Thank you for sending your pictures and providing a detailed description of your jawline surgery goals. While the debate is between a total custom jawline implant or a combined sliding genioplasty with two separate jaw angle implants, for a female and your goals I would choose the latter. The reason is that a total custom jawline implant will make the whole jawline wider from front to back, regardless of the dimensional changes in the profile view of the chin and jaw angles. I don’t think that works well for many female faces. What you want to achieve in the front view is a chin that ends up somewhat more narrow, or at least no wider, as it comes forward, a central jawline that dips in on the way back to the jaw angles and posterior jaw angles that flare out. A sliding genioplasty as it comes forward does make the chin a bit more narrow and it also allows the central jawline to remain narrow. (rather than bow out like a custom jawline implant may create) Your jaw angle dimensional needs is a combination of vertical lengthening and horizontal width for which I already have a variety of jaw angle implant styles to meet those needs.
In the side view you probably needs an 8 to 10mm chin advancement. the jaw angles need a 7mm vertical drop down and a 5 to 7mm width increase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom paranasal implants. I would like custom designs because I do not think that the standard implants will provide enough forward projection. I think I need about 7 to 8mms forward projection while the standard paranasal implants only provide about 5mms of projection at the anterior nasal spine level.
A: While custom paranasal implants can be made, I would opt for what I call semi-custom paranasal implants. These are actually custom paranasal implants made for other patients. But when used for someone else we call them ‘semi-custom’. I have found that the size and fit of most of the custom paranasal implants will fit just about anybody. (and coincidentally they all have been made for Asian patients who are seeking the same aesthetic changes you are) Semi-custom facial implants cost less than custom facial implants. Well-fitting paranasal implants can’t really or become displaced…but I still put a very small screw into each side just to be sure.
A custom paranasal implant can produce a facial effect that is very similar to that of a LeFort I osteotomy. While it does not move the teeth forward like a maxillary osteotomy can, its effect on the nasal base is very similar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am jnterested in lip reduction surgery. I was having problems snoring, went to sleep doctor, dx’d with sleep apnea. He offered CPAP but said corrective jaw surgery would also fix my problem. I went to oral surgeon and will be later this year having both jaws moved forward about 7mm to fix my sleep apnea.
I am interested in an upper lip reduction (we can discuss at the appointment, no problem). My only question is do you recommend I wait until after the jaws are moved forward or can it be done before the jaw surgery? Thanks a lot.
A: Because orthognathic surgery, particularly two jaw advancements will have some lip thinning effect, any consideration of lip reduction should be 3 to 6 months after the procedure. It may well be possible that after orthognathic surgery with the jaws advanced you may no longer see the need to have the lips made smaller. Between the thinning effect on the lips from the jaw advancements and the scar tissue created, it is likely that there will be less vermilion show particularly of the upper lip. As the jaw moves forward it does push the lip forward causing some potential rolling in effect of the lip vermilion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a forehead implant placed three weeks ago, but it seems a little too big. At this point, roughly how much swelling is left from the procedure? I’m just a little concerned as it has been quite a while after the surgery.Thank you for taking the time to read this and it is much appreciated.
A: I am afraid you have my at an informational disadvantage. I did not do your forehead implant surgery, I have no knowledge of what you looked like before your surgery, nor any idea as to the size and dimensions of your forehead implant. This is really a question for your surgeon who implanted it. You had the confidence for him/her to do the surgery, you should have the confidence in what they are telling you now about your postoperative concerns.
But as a general rule, 50% of the swelling is gone by 10 days after surgery, 75% by three weeks after surgery and 95% by six weeks after surgery. This it is still a bit too early to know what the final outcome will be. There is certainly still some swelling that remains so your recovery is still not yet complete.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin and jaw enhancement. I am reaching out to you after doing thorough research in hopes that you could bring some clarity to my concerns and harmony to my face. I am attaching pictures of me in different angles as well as pictures that I have edited with photoshop which reflect a look I would like to achieve. Whether that is possible or not, that is something I trust you with.
I am a female model currently living in Los Angeles. In this industry strong, defined bone structure such as jaw line and cheek bones are critical to a models success and highly sought after. As it stands I have a receding chin that I would like to correct and perhaps dramatize the look of my jaw. In your opinion, what does my face need in order to achieve a more defined look, like presented in the pictures? What are my options? As an out of town patient, planning a surgery requires more resources and time. I am looking forward to hearing your thoughts on improving my face as well as to get a general idea of the cost break down per procedure. Thank you in advance for taking the time to read my email, I greatly appreciate it.
A: Thank you for your inquiry regarding jaw enhancement and sending your pictures. What separates your face from that of the model pictures you have shown are three facial features. The jawline (chin and jaw angles) and nose are the most strikingly different. Besides the shorter chin you have mentioned, your jaw angles are more rounded and indistinct. (unlike the models which are more square and defined) Such a more deficient jawline looks more so because of the size of your nose. (and vice versa)This can be treated by separate chin and jaw angles implants or a sliding genioplasty and jaw angle implants. Coming jawline augmentation with a rhinoplasty would make the most dramatic facial change that would enhance its overall features and bring them into better balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation and have enclosed photographs for your review. I am interested in augmentation of my forehead and brow area. As you may be able to see, my right side is much flatter than my left side and I have a very narrow forehead. I have chin and jaw implants and I feel that my recessed forehead caused my face to be out of balance. I am looking for augmentation to allow for an overall balanced and more aesthetically pleasing look.
Do you believe I need augmentation to the front part of the forehead or just the lateral forehead? Based on your recommendation, how much would such an augmentation cost for PMMA? What are your thoughts about using fat to augment the necessary areas?
A: For your forehead augmentation, you need both central and some lateral fullness. If only the central area is augmented the sides will even more narrow. Such forehead augmentation should not be done with PMMA bone cement since you can’t place a bone cement material past the temporal lines on the side of the forehead where there is not bone. Also PMMA bone cement does a poor job of creating any brow bone augmentation. The type of forehead augymentation you need is best done by using a custom silicone implant designed from a 3D CT scan.
Fat is almost always a terrible idea for forehead augmentation because it survives poorly, has an irregular take and any such irregularities will be impossible to remove secondarily. Fat also produces a soft doughy appearance and not a well defined shape like augmentation of the bone does. A good forehead and brow bone augmentation in a male requires the hard push coming from placing a firm material on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know you warned me that the jaw angle implant recovery would involve substantial swelling for a while. I am at the 2 week mark. I can tell I should not have gone with any ‘drop down’ with the implant. This change is a bit more than what I was looking for. I should have stuck with just 3 mm width, no vertical lengthening. I am wondering what is the next step to getting this fixed. Would I be able to get them replaced with smaller ones (or completely removed)? And, could this happen soon? I am sort of desperate at the moment, I am really sorry. I do need your help on this.
A: I am going to give you some advice on jaw angle implant recovery based on an enormous experience with them in young male patients. You may choose to take it or not and I will do whatever your decision may be.
- I have heard your concerns from innumerable young men who have had jaw angle implant surgery and it is always about the same time period…about two weeks out from surgery. At this point you are far from seeing the final result, both physically and psychologically. On average 50% of the swelling is gone in10 days, 75% in 3 weeks and 95% by 6 weeks after surgery. So while you may think you know what the final outcome will be, you do not. No one can say for sure at this point in the incomplete recovery process. There is also the ‘getting used to’ the new look which takes much longer. So any decision made today is a premature one that could result in an unnecessary surgery.
- The economically prudent and medically advised recommendation is to give the recovery process a minimum of 6 weeks and ideally one should not have revisional surgery for three months after any form of facial skeletal surgery. (temporal implants are NOT like facial skeletal surgery) Any surgery before that time period is really chasing a moving target from an aesthetic standpoint.
- Any surgery before this time period has elapsed is really an emotional one that is not based on logical thinking. I will do it but I need to make clear I do not think it is a wise choice. After three months you may still come to the same conclusion (or not) but at least you will know an undisputable clear idea of the result and how you really feel about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old Asian male interested in head width reduction. I have received a consultation in the past, where I was told the surgery I needed would be very dangerous and expensive potentially even lethal. Is your procedure different? I believe my face is otherwise fine except I have a very wide head above my ears. I have a smaller chin so my head appears unbalanced. Would I benefit from surgery? I noticed you also use Botox to good effect. Could I try the Botox first to see how it looks and then go with the surgery if the result is good? Looking forward to your advice.
A: The statements that you have been told about posterior temporal reduction (head width reductio above the ears) are completely untrue. There were obviously made by surgeons who have no experience in this type of surgery nor understand the anatomy of the area. The majority of the width of the size of the head is made up of muscle not bone. The posterior temporal muscle width is as much as 9mm in thickness. When this is reduced through a very straightforward and effective procedure with no side effects and very minimal recovery, the change in the width at the side of the head can be dramatically different. If you do the math, up to almost a 2cm width reduction in head width can be achieved. This is particularly true in Asians males where the thickness of the temporal muscle is quite significant. There are no adverse functional effects on jaw opening by removing this portion of the muscle.
While you can certainly do Botox first, it will not create the same head width reduction effect as this type of surgery. But there is never any harm in doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about facial feminization surgery. I was wondering the prices of the surgery and whether insurance many cover some of them. I am a 32 year transgender male to female.
A: As you know Facial Feminization Surgery is a compilation of a variety of facial procedures which differs amongst each patient. The first step is to determine which facial features would benefit most by changes and establish a priority list of what the are from most important to least important. This requires considerable input by the patient themselves. You probably have a good feel for the facial areas that you think would make the biggest difference in a more feminine facial appearance. I would ask that you listen for me the top three in your assessment. Once we have a list of procedures then you can be provided pricing.
As for insurance coverage for facial feminization surgery, that is very rare…but I have seen it occur. The way to determine if insurance would potentially cover any of these procedures is to file a predetermination letter. It is up to the insurance company, not the surgeon, to make that decision. All I do is provide them with the information needed. That required information would be the following; a set of facial photographs, documentation from a physician/ therapist that states that these procedures are medically necessary and the patient is a good psychological candidate to do so and a list with procedure codes of the facial operations needed. The latter is my my responsibility as well as the composition of the letter, the fist two are your responsibility to get to me.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an Asian male interested in custom cheek implants. Is it possible through custom implants to add lateral projection to the zygomas? What would be the maximum lateral projection the implants could give? (Iam hoping for at least 1.5cm to each zygomatic, but 2cm each would be ideal). I am after a look of very prominent cheeks to go with a very prominent jawline (also through implants) similar to the guy in this picture (note his flanged and very prominent cheekbones) Thank you for your assistance.
A: When it comes to designing custom cheek implants, any size or dimensions of the implant can be done. In making these designs and in looking for an ‘extreme’ facial look, one only has to be vigilant of two issues. First, one must make sure that the size of the implant does not preclude a good and competent intramural soft tissue closure over them. The stretch on the cheek tissues in very large implants can theoretically cause such an issue which would be disastrous if wound breakdown occurs postoperatively. Fortunately the cheek soft tissues are fairly elastic and have a lot of give to them. Secondly, one must avoid making an implant that is too big and thus creating the need for revisional surgery. The actual site and thickness of a cheek implant to create the look you are desiring is probably less than what you think. I have placed cheek implants up to 1 cm in thickness on each side and it can be impressive as to how much change that creates. I would doubt that you need 1.5 cm to 2cms of width on each side to achieve that cheek augmentation look. Dimensions such as those does run the risk of oversizing and the potential need for a revisional surgery to downsize the implants.
Dr. Barry Eppley
Indianapolis, Indiana
