Your Questions
Your Questions
Q: Dr. Eppley, I was previously going to have a chin implant with screw fixation. At the time, I was planning to get one and was planning to consult with you. I’ve done a lot of research since that time and have come to the realization that I’d like to address my issues with bimaxillary advancement as my entire jaw region isn’t adequately projected and I have a “fleshy neck” appearance in photos and on video. My airway is also smaller than it should be and obstructive sleep apnea is an issue.To the point – I’m debating getting a sliding genioplasty in conjunction with my bimaxillary advancement to advance the chin horizontally. I want my chin to be closer in line with my lips and I did not know if bimaxillary surgery alone would address this or not. Would a sliding genioplasty be a bad idea (too deep labiomental fold afterward)? Thank you
A: Having done lots of orthognathic surgery, including bimaxillary advancements, the only reason to pursue that course is for the purposes of improving sleep apnea. From an aesthetic standpojnt, bimaxillary osteotomies along would not cure the weaker chin and fleshy neck appearance that is of concern to you. That anterior movement of the mandible, in the range of 6 to 8mms, would help your chin projection but since the upper jaw is coming forward it would not provide the ideal correction. Cephalometric tracings would verify the accuracy of that statement. A sliding genioplasty would still be needed to provide the aesthetic goal of making the chin be closer in line with the lips. The bimaxillary advancement would make the amount of amount of the sliding genioplasty less however. All forms of chin augmentation, including a sliding genioplasty, will make the labiodental sulcus deeper. That is unavoidable but a 4 to 5mm sliding genioplasty advancement would not make it that much deeper or would make for a minimal adverse change in its depth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in nerve repair. I had eyebrow hair transplants three times. The last time I had done was over one year ago. Since then I have had electric, shock like, tingling, numbness pain and crawling sensations that are felt along the eyebrows and down sides of nose. Smoking and stress worsen nerve pain and nothing relieves it. It lasts all throughout the day. I feel I have had a nerve cut in that area and wondered if I would be a candidate for surgical repair to this area? It causes much distress in my life. I would be happy to hear any input from you
A: With eyebrow hair transplants I can theoretically see that injury to the nerves under the eyebrows could account for either pain or sensory loss by either the injection of a local anesthetic into the eyebrows or from the creation of a needle tract for the placement of the transplanted hair follicle. The distribution of the pain should help determine if this could be the source.
The only nerves that are under the eyebrows are the supratrochlear and supraorbital nerves. In detailing the anatomy of the supratrochlear nerve, it is a branch of the frontal nerve (1st division of the opthalmic division of the fifth cranial nerve. It comes out right below the inside the brow bone and comes up onto the forehead in the glabellar muscle region. It supplies feeling to the skin of the upper eyelid and the glabellar region of the forehead. The larger supraorbital nerve, also a branch of the frontal nerve, comes out either right under or on the brow bone right below the inner half the eyebrows and supplies feeling to the frontal sinus and skin of the forehead all the way up into the scalp. As you can see from this anatomical description, injury to either of these nerves does not account for the distribution of the pain down along the sides of the nose. That is the vexing part of your pain symptoms
But using the analogy where there is smoke, search for a fire. It is fair to say that it must be some type of injury to these nerves. At this late date, actual repair of a cut nerve if it existed would not be possible. All that can be done at this point is an endoscopic approach to decompress and release the supraorbital and supratrochlear nerves, possibly wrapped in fat graft to prevent secondary scar tissue formation around them. This is exactly what is done in migraine surgery. Whether this would work for you is unknown. One test you could do is to inject Marcaine local anesthetic around these nerves to determine of that provides temporary symptom relief. If it did that would provide you with great confidence that is the source of the problem and an endoscopic release may provide some symptom improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it is hard to find a good scar revision specialist who can answer some basic questions without a formal consultation. As you have already answered my initial questions in regards to my scar, I would like to ask you my most important last question that is still on my mind.I still have not decided what to do about my scar. The best treatment would be excision as most of the doctors have recommended. But the reason why i still have not gone for excision is that I do not like the fact that my scar will be much longer. My chin scar is 0.3 cm wide and 0.5 cm long now. I had a prior consultation with scar revision specialist and he said that scar will be about 1.2 cm long after the revision which I do not like. He would place it in a curved or oblique line that parallels the curve of my chin pad – this is called a resting skin tension line (RSTL). I saw many scars after excision so why some of them are not so long even though they are as wide as mine. I would appreciate your answer.
A: The best treatment for your scar is a two-stage excision scar revision approach that does not make the scar any longer. The problem with your scar is that it is wide over a tight chin area. While it can be removed as a single stage procedure, the scar length would nearly double in size. Because of its width it is best served by doing a subtotal excision, let it heal for three months, and then doing a second stage completion scar revision. This is the only way to improve your scar without making it any longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I understand if this is an upper blepharopasty question you cannot answer online, but I was wondering if I could get your honest opinion regarding my eyelids. Although I’m young, I’ve always felt they are unusually droopy and asymmetric. In particular, I do not like the excess skin of my left eyelid. I understand that my case is a little weird and subtle, so I would appreciate your honest opinion whether surgery would actually benefit me or not. Thank you very much for any information!
A: In looking at your pictures, you do have an extra skin roll on both upper eyelids of which the left side has the greatest amount. A limited upper blepharoplasty of either just the left upper eyelid or both eyelids would be beneficial and a very straightforward procedure to go through with a very short recovery. One’s age really does not matter, what counts is what is the anatomic problem and is it correctable. This is your natural eyelid anatomy and if it bothers you this is a very minimal to no risk procedure to undergo. Upper blepharoplasty scars are very minute and usually not visible even with the eyelids closed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had the chin implant placed three years ago. It’s not a huge issue for me, but I think it should stick out a little more to be more proportionate with my lips and nose. Also, from the front I feel like it looks kind of square. Ideally, a little more narrow in the front if that’s possible? As far as the jaw implants, I just want to have definition. I definitely don’t want to look masculine. I just want my face not to melt into my next like it does now.
A: Thank you for sending your pictures. Your existing chin implant is still abut horizontally short, sits vertically high on the chin and is most definitely very square. Your chin implant revision should provide more horizontal projection (about 3 to 4mm), be positioned a little lower and be of a style that provides a more tapered chin look from the front view. It appears that your initial chin implant was placed using an intraoral approach. Your chin implant revision can be done in a similar fashion.
Your jaw angles are high and some vertical lengthening of the jaw angles with just a bit more width would complete your jawline makeover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am looking to get a breast lift revision. I had breast implants and a periareolar breast lift performed over one year ago . Since then I’ve had three nipple revisions due to inconsistent shape and size. I am unsatisfied with the result and I am in need of new approach to hopefully fix what I have left. To deal further, I had the initial procedure done 18 months ago. I’ve had two revisions on my nipples since then. My left nipple continued to be more oval and larger then my right. My right I was very pleased with. The most recent revision was done to correct my left nipple as well as lift the breasts, as my original inframammary fold was showing upon any flexion. Both nipples were revised and I developed on infection on my right side. A tip of nylon suture had migrated to the skin surface and caused the infection. There is also a dark spot on my left nipple were I can only assume is nylon as well. Please see if there can be a revision done to restore my feelings of happiness in having this done. I feel very much like Frankenstein and embarrassed with my bra off. Although if more time is needed to pass and I just need patience for them to heal? I don’t have a good feeling that they will. I’ve attached photos of my recent outcome. Thank you so much.
A: Thank you for sending your pictures and detailing your history. It appears that you have had an original periareolar mastopexy (donut lift) with your implants and have been battling areolar asymmetry and hypertrophic scars since. I am not a fan of the periareolar mastopexy as I have seen too many patients go down the road you are traveling. But despite the revisions maybe it is still worth it to avoid the scars from a vertical breast lift. (although they have a much lower risk of these problems than the periareolar mastopexy) The reason is that all the tension of the lift and the implants is placed on the areolar closure. Inevitably they widen and have hypertrophic problems frequently.
But that is water over the dam so to speak now. The question is whether a third areolar revision (breast lift revision) would be beneficial. Despite having two ‘failures’ at them I would still remain an optimist. But you would ned to wait at least 4 to 6 months if not longer to let the scars mature first. Redoing the areolar scars too soon is just a set up for recurrent hypertrophic scar formation as the scar tissue is still inflamed and highly reactive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question regarding surgery on lower lip sag. I show a lot of teeth (all my lower teeth) when I smile or talk. I have had a few genioplasties which I worry may have caused it to be like this. Also had braces before which may have more my teeth up. Is there any way to fix this? Like a lower lip suspension? I don’t know if it is scar tissue or what it is. I already have full lips so filler would not be very beneficial. Also I am a guy so I don’t want filler to thicken my lower lip. I don’t know what to do but I am so self conscious about this. Do you think the previous scar tissue needs to be removed from the chin area and resutured with more skin lax above the suture so the lips can spring back up ? Is that even possible? I have heard Botox doesn’t really do much to the lower lip and only moves upper lip down which I don’t want to do as I don’t want a long upper lip. Hope you can help.
A: Correction of a lower lip sag is a very difficult problem and often unrewarding surgical effort. The traditional approach to treating it would be a resuspension of the mentalis muscle through an intraoral approach. Althugh having done this many times, it is unsuccessful more than it is successful. It works best when it is combined with chin augmentation or a sliding genioplasty since it adds to the upward soft tissue support.
In reality the lower lip sag is more of a soft tissue defect than one of malposition when it comes to surgical correction. From that perspective, grafting the vestibule with a dermal-fat graft along with the muscle suspension makes the more sense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck but don’t know too much about it. What type of tummy tuck do I need? Should I try and lose more weight before? Although with my back injury and being on disability I don’t see any significant weight loss happening. I have attached some pictures of my overhanging stomach for your review.
A: Thank you for sending your pictures. What you have is a large abdominal pannus and thick abdominal tissues. What you would ultimately need is really an abdominal panniculectomy rather than a classic tummy yuck. Your abdominal tissues are too thick an your weight is too high to do accomplish anything more than an extended abdominal panniculectomy. While such a procedure would clearly have great benefit, ideally you should lose a lot more weight to have the better abdominal reshaping procedure. But for many patients weight loss is difficult and an abdominal panniculectomy now is better than nothing at all. That would have to be a decision that only you can make and I think with your back injury that decision has already been made.
You should clearly understand that an abdominal panniculectomy is not the same as a tummy tuck. It is a less refined although larger amount of abdominal tissue removal whose main objective is to eliminate the overhanging abdominal tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions/concerns about a forehead implant on what can be done over it after it is in place. Would I be able to have Botox injections in my forehead after getting the implant placed by you? Or would this inhibit the ability to do Botox injections there? I also will need a thickening hair transplant in the very corners (temples) which I will do after we do the forehead implant but I want to be sure the transplant can still take to the forehead even if the implant is directly underneath it because I want the forehead implant to raise high up.
A:You should have no problems with getting Botox injections after having a forehead implant placed…as long as the injectors knows not to inject down to the ‘bone’. (that would be a waste of Botox and risks implant infection) Botox injections are placed right under the skin into the muscle not deeper. Also doing further hair transplants after getting a forehead implant is no problem since the implant sits well below the skin level down at the subperiosteal plane. Everything aesthetically you want to do after this type of facial implant is placed is more superficial to it and is perfectly safe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very happy with the buccal fat removal and perioral liposuction you did on me a few years ago. I still feel that my face lacks definition though and have been researching lower jaw surgery/sliding genioplasty and vertical lengthening chin implants and wondering if one of those procedures would be beneficial for me to get that angular, taut lower and mid facial structure that a lot of models have. A jaw/chin that has extra projection seems to produce a concavity in the para nasal area that think is really pretty…I know I have an overbite but it’s not severe and I am hoping to avoid having to go through orthodontics and jaw advancement IF a sliding genioplasty and/or a custom chin implant would yield the same results. I have attached some photos of the look I am aiming for (as well as one of myself for reference) and would like to know if you think I could get close to my “ideal” with a genioplasty/implant or if lower jaw advancement is really the best treatment (for aesthetic purposes only). I always feel myself involuntarily jutting my lower jaw forward (it feels more comfortable that way and it also makes my face look better). My face just looks better from ALL angles when I’m projecting my jaw forward. Since I’m already 31 I would like to get started right away, especially if the best choice is jaw advancement since I would have to have braces before and after that.
A: To best answer your question about chin lengthening, I have done imaging based on some old pictures that I have of you of a combination chin lengthening and small jaw angle implants for the more complete jawline effect. You definitely do not need to move the whole lower jaw with orthodontics. That would not produce the same result. The choice is really between a sliding genioplasty vs a custom V-shaped chin implant. Both theoretically could achieve the same longer chin, they are just two different ways to get there. You already have a pretty V-shaped chin and you are young so I am leaning towards the sliding genioplasty because it is more ‘natural’ and would even accentuate the V-shape of your chin. I simply put in the small jaw angles just to give you a little more width and squareness to the back of the jaw…which is what all those models also have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck later this year. I work out five days a week lifting weights and and eat a high protein based diet. I am 220 pounds and 6’ 2” feet tall.mI am trying to get down to 10 percent body fat and stabilize at 190 pounds. My trainer predicts that we can achieve that in 6 months and that is when I would like to have the tummy tuck surgery. My lower body is all muscle but I have a very fatty upper body. I have significant visceral fat and of course subcutaneous fat below the skin which will be removed during the tummy tuck. My weight has fluctuated a lot in the past which has resulted in a very lax bulging abdominal wall and stretch marks on the skin. I was recommended to have a full tummy tuck with flank liposuction and central abdominal liposuction as well. But I don’t want central abdominal liposuction, I don’t want to risk any healing and circulation complictitons. It can be done later after the tummy tuck. I have attached pictures of my stomach for your review.
A: Thank you for sending your pictures. I would certainly agree that your tummy tuck should wait until you have maximized your weight loss. That is the only way to reduce your visceral fat component of your abdominal protrusion. This will also allow for the most extra skin to be taken during the tummy tuck as well. I would also agree that any abdominal liposuction or etching can be done as a second stage procedure. That is both safer and more effective when done that way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 28 years old and would like to discuss a lower blepharoplasty with fat repositioning. I should say that I have researched this quite a bit and understand the different options. I am only unsure of whether I need the transconjunctival lower blepharoplasty with fat repositioning into the tear trough at all versus whether I would perhaps only need lower eyelid fat injections without a blepharoplasty. I don’t want synthetic injectable fillers.I am attaching some photos for your review. I don’t have excess skin that would require the subciliary incision. Unfortunately, the photos don’t do justice to show that you can actually see several of my veins through my lower eyelid skin. The photos seem to always filter that out but in person, the circles are quite dark and the skin quite thin. I do not have pigmentation of the skin, however- it’s definitely due to the underlying structures. Thank you so much!
A: Thank you for your description and the comprehensive set of pictures sent. They all lead to the following:
1) Your young age and lack of any excessive skin eliminates any open lower blepharoplasty needed.
2) You do not have any herniated lower eyelid fat so fat transposition is not an option.
3) As you may have already concluded, fat injections would be the appropriate and only treatment option. (given that you have excluded synthetic fillers)
Fat injections to the lower eyelids is an exquisitely technique sensitive procedure in the very thin cover of lower eyelid skin. Over correction and lumpiness is not rare as the flow of concentrated fat is not linear due to its more irregular shaped globs of fat that are harvested and concentrated. I have learned to process the fat into an emulsified form to create a more even flow of the material as it is delivered through a microcannula for placement. I also like to add in PRP (platelet-rich plasma) with the fat to get the potential benefits of its growth factors on the cells. In a low volume injectate like that of the lower eyelids the ratio of fat:PRP would be quite favorable
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a chin reduction in the near future. However, I have been considering having lip implants (Permalip) before surgery on my chin. I was wondering if the implants would in any way hinder a chin reduction surgery? Would it also depend on whether an intraoral method was used? Thank you.
A: You are correct in making the connection between lip implants and intraoral chin reduction surgery. If you were having a submental type of chin reduction (an incision done on the underside of the chin) then having lip implants done at the same time would not matter. But if you were going to have the chin reduction done intraorally it would be advised to either do the implants at the time of the chin reduction ( chin reduction first and the lip implants as the second part of the procedure) or afterwards… but not before.
Permalip lip implants can be an effective and permanent method of lip augmentation. But they require careful placement in the lip tissues and should not be disturbed by traumatic stretching after their implantation until well healed. Thus it is best that they be surgically placed after other oral or facial procedures have been performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if sagittal ridge skull reduction plus/minus skull augmentation is an option for me. I went to my doctor with this and had an x-ray, head CT, and bone scan done. A surgeon then biopsed this ridge about two months ago. The biopsy showed benign fibroadipose tissue which he tried to take as much of that tissue off as he could. The surgeon also told me the rest of the ridge is bone. I would like to have this extra bone removed so I can achieve a more natural head shape. The ridge measures approximately 7 cm long x 2.5 cm wide x 0.5 cm high. Of note, I have a healing scar from the biopsy that is about 5 cm long that is midline and runs anterior to posterior over the ridge.
A: Your pictures show what appears to be a classic sagittal ridge skull deformity. I have not seen the x-rays but that entire ridge would be expected to be solid bone. I do not know why a ‘biopsy’ was done nor why there would be a sagittal incision of that length for it….but that is past history now. Using that same incision sagittal ridge skull reduction could be down by a bone burring technique. It would be help to see the thickness of the sagittal ridge on the CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in the process of reaching my ideal weight and have been researching tummy tuck surgery I have had two children via c section and I have been over weight/obese for many years. I am currently 5’5″ and weigh 227. I have lost 60 pounds so far but I’m wanting to lose another 40-50. I was wondering when I should start the tummy tuck process with a consult? I know I have a ways to go but I wasn’t sure what the requirements are before having a consult. Do I need to reach a certain BMI or be within so many pounds of my ideal weight? Like I said I’m just researching now and trying to plan for the future. I have double rolls of skin/fat around my abdomen and a lot of sagging already. I’m sure part of that will shrink but I also know I need muscle repair too. Thank you so much for your time and any info you can provide!!
A: Congratulations on your weight loss. This is a great question and a very proactive one. As a general rule when there is weight loss needed before a tummy tuck, one should not have the surgery until one is within 10 to 15 lbs of their weight goal. However, when one is undergoing extreme amounts of weight loss (bariatric surgery or otherwise), one may find that there comes a point when the skin rolls and their ongoing persistence (your skin rolls will not shrink much if at all) will cause one to consider where surgery may need sooner rather than later. I would continue with the weight loss until you hit the proverbial wall and no further change in how you look has become apparent. Then it is time to have a tummy tuck, or what is more likely an extended tummy tuck or body lift, consultation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wondering how augmentation of the zygomatic arch is done. Is it possible and is it safe to do? It seems that it would not be much different than getting cheek implants.
A: Zygomatic arch augmentation is permanently done by placing an implant from inside the mouth, very much like a cheek implant. (only further back to the temporal bone in front of the ear. This is easiest and most consistently done using a remade implant as opposed to filler, fat or any other type of material injections. Zygomatic arch augmentation can be done alone or in conjunction with the cheek as an extended cheek implant. It is ideally done using a custom made implant for an exacting fit but in some cases may be able to be done using a ‘semi-custom’ approach. (semi-custom means using a custom zygomatic arch design already created for another patient) There is not that much variation in the shape or curve of the zygomatic arch amongst most people. As you may know there is no specific zygomatic arch implant available off the shelf or premade. So zygomatic arch augmentation must be done by making the implants for each patient. (custom vs semi-custom)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a facelift. I always thought that it would never come to this desire but it has. My goals are to lift my sagging cheeks, reduce the marionette lines some and hopefully ease few wrinkles out of chin. I’m not wanting to look 30… but 55-60 would be nice. I’m going to be making a series of videos of me for my work and the producer wants me to look like a grandma. I would rather look like the kids’ dear auntie. Vanity, vanity….I’ve always known that so I’m good with it.
A: In looking at your three facial rejuvenation goals, they are all exactly what a facelift does NOT improve. A facelift is largely a neck and jowl improving procedure for the lower face. It has not effect at all on the chin, mouth or marionette liens of any significance. It has does not lift the cheeks. Each of your three facial concerns have to be treated by different procedures. Chin skin wrinkles can only be reduced by laser resurfacing, there is no lifting procedure for them. The cheek can be lifted but that has to be done with a cheeklift or midface lift. This is done through the lower eyelid approach so the cheek an be lifted vertically. In some cases, submalar cheek implant can lift sagging cheeks. Your type of deep inverted marionette lines are the most challenging since any type of injectable filler or fat injections will barely make an improvement in them because the line is inverted like a V…this makes it very hard to push out. The best treatment is to excise them and trade-off into a fine smooth line. That would remove them completely but is really done except in older marionette lines that are very deep.
All three of these facial procedures could be performed together and are a lot easier to got through than a traditional facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 23 year old male and i have a concern about my headshape. My head is looking very small on my body, although I have an average circumference of 57 cm at a height of ~180cm. I have a slim face, but the main problem is, that my head gets narrower too much at the top, so it’s a little bit shaped like an egg. I have a long neck and wide shoulders, in combinations of that, it looks just weird. I already read at your page what can be done , but I have still some concerns about getting an implant. Is there a guarantee that it is lasting a life long? Is it as hard as bone, so if someone touches my head will it feel like real skull? And is there a chance that it can move / slip around after some time? I just want to solve this problem and never be confronted with it again, so I am looking for a permanently and safe solution.. What other options do I have if don’t want to get an implant? Can the bone be restructured, or is it as risky as it sounds?
A: In answer to your skull implants questions:
1) The only safe and effective skull augmentation method is an implant. Moving/expanding the skull bone is not an option in an adult.
- Skull implants will last a lifetime, will never breakdown or degrade or need to be replaced. They are made of a polymerized silicone material that will only break down at temperatures of greater than 375 degrees F.
- Skull implants will feel just like bone and will not move around or become displaced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have always been insecure about my head shape and I wanted to know what exactly can be done and the cost. I would like a forehead reduction and the back of head reduction as well. I have provided a left and right profile image of my head. Please advise on what can be done. My head isn’t extremely large its just my forehead sticks out too much for my liking and also the back of my head but tell me your honest opinion. Thank you.
A: Thank you for your inquiry and sending your pictures. While both the forehead and back of the head protrusions can be reduced significantly, my concern is the resultant scars from the incisions to do. The back of head reduction is less of an issue because a relatively small horizontal incision can be made directly over it to reduce it and that scar line always heals very well. The only reasonably acceptable incision to approach the forehead is through a hairline incision right at the edge of the hairline.While that usually also heals very well, it does gove me some pause with your ethnicity and type of hair.
In my opinion the back sticks out further and is more ‘abnormal’ than the forehead but I think you probably feel the opposite about the two…and your opinion is really the only one that counts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to know if you can greatly reduce the size of my prominent frontal bossing. This part of my skull that is currently protruding out of my forehead and causing my hair to fall out? Can it be reduced as well as lower and restore my hairline in the process? The reason I ask this because since my skull expanded my cranial and facial appearance has been altered and I wish to revert this process. If you could please let me know what steps one usually takes from here I would be really grateful.
A: Thank you for your inquiry and sending your pictures. Your frontal bossing can be reduced fairly significantly and the frontal hairline brought forward. How much the frontal bossing can be reduced depends on the thickness of the bone. How much the frontal hairline can be brought forward depends on how much laxity of the scalp exists after it is elevated. While both can be simultaneously accomplished, one issue is that there will be a fine line scar at the edge of the hairline. This is the dual access point for both procedures. Since frontal bossing is not the source of hair loss, the long term consequences of having a fine line scar there and the fate of the hairline in the future bears giving consideration as to its advisability.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I been looking Into skull reshaping procedure for years now, and your website has been very helpful. But I need the back of my skull shaved down but I can’t find no information on numbness? So do this area come with numbness and if so long long can it last?
A: Every time a scalp flap is raised to perform any skull reshaping procedure, whether it be augmentation or reduction, there will be some numbness that will occur over the raised scalp flap areas. Most of this numbness is temporary and is self-resolving over time. I have yet to have a patient tell me that they have any bothersome numbness on the back of their head after any occipital skull reshaping or reduction procedure.
On the back of the head coming up from the sides at the base of the skull are the greater occipital nerves. They supply a lot of the feeling across the back of the head as well as coming further forward along the scalp. These nerves run above the bone in the soft tissues of the scalp. Any type of skull reshaping procedures raises the entire scalp off of the bone, thus the nerves are protected from being injured or cut which would be a cause of permanent numbness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction. Since high school I’ve had a prominent forehead and found it hard to accept. Now ten years later I have decided to do something about it. I have read on your website and checked out the various methods and then decided that the only method that would work for me is directly through the forehead because my hairline is receding. I don’t really have any deep forehead wrinkles but it is the only option. I have attached pictures for your review.
A: Thank you for sending all of your pictures. In regards to the type of forehead reshaping you need the question is whether this is a brow bone reduction (to bring the brow bones back to the level of the upper forehead) or whether it is to build up the forehead above the brow bones to correct its slope. Just based on forehead aesthetics for a male, I am assuming it is the latter. A custom forehead implant is made from a 3D CT scan.
Conversely brow bone reduction can also be done. In your case the brow bone reduction may only be a burring of the most prominent portion of the outer table where it bulges tyhe most.
You are correct in that a limited horizontal forehead incision would be the only reasonable incisional approach. Fortunately custom silicone implants are very flexible (until they situ against bone) and thus can be inserted in a rolled fashion and then unfurled once inside. That at least will keep the horizontal forehead incision more limited, perhaps in the 4 to 5 cm length. The location of the incision would be determined by raising your eyebrows and seeing where the eventual deepest horizontal crease will eventually be. Placing it there will usually lead to a pretty good scar result. The exact same type of incision would be used for any form of brow bone reduction as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation. I have a very odd head shape which really causes me to struggle with every day life. I would seriously consider surgery if It would help me have a more natural looking head shape. I have attached a couple of photos. Ive never spoken to any one about it as no one has that head shape like me and doctors wont be able to do anything and i’ve never seen anything about skull surgery except from the service you offer. I hope you can help.
A: Based on the pictures you have provided, what I see in a flat area on the upper back of the head. If this is your concern, it is not rare in my experience and is the single most common female skull shape concern and surgery that I perform. This is ideally treated by a custom skull implant made from a 3D CT scan. The amount of skull augmentation possible depends on the amount that the scalp can stretch. Usually most natural scalp laxity can accommodate an implant up to 12 to 15mm at its central thickness. Greater amounts of skull augmentation (20mm plus) require a first stage scalp tissue expander to create the looseness and amount of scalp tissue needed to safely cover a thicker implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about jaw angle implants. I recently saw a question on your blog regarding the inevitability of massteric pterygoid sling disruption when there is vertical lengthening of the jaw angle and was wondering if you could elaborate a bit further on the aesthetic impact of this disruption (specifically, the masseter muscle “roll up” that can occur). Does this mean when the jaw is in a normal position, the bulge of the masseter is going to visibly rest higher than the very bottom of the jaw angle? With lengthening of 10-12 mm, is this effect very significant? I was hoping you may have some sort of visual representation of this effect so that it can be more clearly understood – it seems to be a potential negative drawback of too much vertical lengthening.
A: By definition any vertical jaw angle implant lengthening causes some disruption of the masseteric-pterygoid muscle union along the bottom edge of the jawline over the mandibular ramus area. This is inevitable and a consequence of the procedure. But this does not mean that it is always an aesthetic problem. I have done many vertical lengthening jaw angle implants and custom jawline implants (some as long as 25mms), I would say it was only a bothersome aesthetic consequence in less than 10% of the patients.
Disruption of the masseteric pterygoid sling can cause two aesthetic (no functional) problems. When biting down, the bulge of the massteric muscle can be seen to be higher than the actual skeletal/implant jaw angle location. Or they can be persistent fullness above the jaw angle that prevents a well defined jaw angle definition (or flare of the jaw angle) to be seen. There is no way to predict beforehand what type of vertical lengthening jaw angle implant patient this aesthetic sequelae may be seen in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about temporal artery ligation. I have two prominent vessels on my temples. They are actually not veins. It’s a temporal artery on both sides of my head. I’ve spoken with two doctors who said to leave it alone. Here are pictures of them. I was told these are arteries, not veins. Both doctors told me that they should not be removed as they supply blood flow. Sometimes they’re not very visible but that’s usually when I’ve just woken up in the morning. I have a little bit of high blood pressure and I’m on medication for it. Anyhow, I’m not really sure what to do. I didn’t have these a few years ago but as I’ve gotten older they’ve gotten worse. I really don’t want to have permanent scars from a procedure.Thanks.
A: Thank you for sending your temporal pictures. These are classic enlarged anterior temporal branch arteries from the bifurcation of the main trunk of these superficial temporal artery. They will be more noticeable with your blood pressure is higher, when exercising or when in hotter temperatures due to the increased blood flow in them. Whether you have them treated by temporal artery ligation to reduce their visibility is a personal decision. But if you were to do so, this is a perfectly safe procedure that is done through very small incisions in the temporal hairline and possible a very tiny one at its end at the side of the forehead. These small incisions do not create scarring concerns. The forehead and scalp have such a redundant and extensive network of blood supply that reducing flow through these vessels will not cause an harm in so doing.
Dr. Barry Eppley
Indianalpolis, Indiana
Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had my primary rhinoplasty done six months ago. The method used was diced ear cartilage wrapped in fascia to increase bridge and tip height. What I’ve noticed in my bridge is that it slightly decreased in height possibly due to swelling going away. With the swelling gone, the bridge height isn’t as augmented as I had wanted. For a revision,I wanted to know if Dr. Eppley would consider using the diced cartilage injection technique.Looking for very slight increase in bridge height.I feel that cartilage injection best suits my case.That minor change can make a huge difference. As I have read in some of your articles concerning revision rhinoplasty, many patients desire a revision rhinoplasty because they may be seeking the optimal look for themselves and may not be a result of aesthetic unhappiness with what their previous surgeon performed. In my case, I feel as if my surgeon did an excellent job with my rhinoplasty. My only issue now is that I was extremely gratified in the first three to four weeks with my nose but failed to realize that the swelling played a role in that. Now that the swelling has almost subsided completely, I am looking to add enough bridge height to replicate what it looked like in the first month post surgery. I can’t stress to you enough how little of an increase in bridge height I am desiring, but it’s enough of a change to make a huge difference for me.
A: Thank you for our detailed rhinoplasty history. For a modest increase in dorsal height, I would agree that an injection of diced cartilage, done through an intercartlaginous incision, should be appropriate.While the concept of an injection always sound simple, it is important to note that cartilage must be harvested, prepared and then injected. The question is where that cartilage should come from…the contralateral ear or the septum? Either way this usually requires more than a local anesthetic in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am seeking a facial profile enhancement. I am not happy with the way my profile looks. I would like your recommendation. I have a deviated septum so a rhinoplasty at the same time might be possible? I also have an overbite and I was wondering what you would recommend for receding chin… orthodontics or cosmetic surgery.
A: It is very common to do a septoplasty and rhinoplasty at the same time, known as a septorhinoplasty. You do have a short chin and treating its deficiency combined with neck liposuction would provide the best result. With an existing overbite the question is how significant it is and whether you are prepared for the commitment of a combined orthodontic-jaw advancement surgery treatment program. (orthognathic surgery) If not then a chin implant or sliding genioplasty would be the cosmetic treatment options. A rhinoplasty, chin augmentation and neck liposuction could all be done at the same time for a significant facial profile change. (facial profile enhancement)
A combination of nose, chin and neck changes can make for the most powerful and significant change in one’s facial profile that is possible. It usually takes at least two changes in one’;s face to create the optimal facial profile enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom skull implant. The back top of my head is flat and I plan to do something about it. my questions are the following:
1. what materials are available and what would you recommend?
2. will the implant affect hair growth, (in some way?)
3. what is the cost and time to recover?
4. side effect, pros-cons ?
I greatly if you can answer these questions for me and looking forward to hearing from you!
A: In answer to your custom skull implant questions:
1) By far the best method of skull augmentation is a custom made silicone implant fabricated from the patient’s 3D CT scan.
2) Skull augmentation with a subperiosteally placed custom skull implant does not affect scalp hair growth.
3) My assistant will pass along the cost of surgery to you on Monday. Recovery is fairly quick with minimal downtown other than some scalp swelling and some mild discomfort.
4) The benefits to a custom skull implant is that it is best method to get the smoothest and greatest amount of skull augmentation with the smallest incision. Its downsides are that it does require an incision to place it (7 to 9 cms long) and may or may not be able to achieve the desired amount of skull augmentation as a single stage procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a forehead widening and brow bone implant. Is it possible to get a wider forehead like in the attached picture and a brow bone similar to the one in the second atached picture in one combined procedure?
A: Such forehead and brow bone changes are possible under the following two circumstances;
1) a custom forehead implant with a brow bone extension must be used which is designed off of a 3D CT scan of the patient, and
2) a coronal scalp incision would be needed and the resultant fine line scar for its placement.
While smaller brow bone implants can be placed through small scalp incisions using an endoscopic technique, as soon as the larger forehead component is needed a much larger open scalp incision is needed to ensure proper placement.
The wider forehead comes from making the custom forehead implant extend beyond the anterior temporal lines on the side of the forehead. In essence the the implant creates a new temporal line more lateral to the existing one. This also requires that the implant extend down inferiorly on top of the temporalis fascia into a fine feathered edge so that there is no visible implant edge transition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My rhinoplasty is tricky as my stiff columella is my main complaint. wonder if the actual columella bone can be shaved without addressing the tip of the nose. I have read about anterior nasal spine reduction but I am not sure what that is. I am open to suggestion.
A: The reason that your columella is so stiff is that you have a prominent anterior nasal spine. This is what you refer to as the ‘columellar bone’. The end of the nasal septum, which sits behind the columella of the nose, rests on the anterior nasal spine. The longer and more prominent the anterior nasal spine is on the maxillary bone, the more forward will sit the end of the septum. This causes a very open nasolabial angle (angle between the base of the nose and the upper lip which inn most men should be about 90 to 95 degrees) and a very firm and stiff feeling columella. The anterior nasal spine reduction procedure removes the bony prominence and the base of the end of the cartilaginois septum that attaches to it will allow the nasolabial angle to sit back, decreasing the tension on the columella and the upper lip. This can be done by itself or one of the many maneuvers in an overall rhinoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
