Your Questions

Q: Dr. Eppley, what can be done about my eye asymmetry? My whole left eye is about 5mms lower than that of my right eye. What is the best way to amend this problem?

A: To correct your orbital box eye asymmetry, multiple adjustments need to be made to the orbital floor (augmentation), brow bone (inferior reduction) as well as upper eyelid (ptosis repair) and lower eyelid (fat injections and lateral canthoplasty) The issue is that the bone changes will cause problems with the current eyelid positions and then these will need to be adjusted. I have treated many cases like yours and sometimes you open ‘pandora’s box’ by trying to make these changes. The position of the eyelids is perfectly aligned to the bony orbital skeleton now albeit lower and asymmetric that it is. Once changes get made to the orbital bony box, the eyelids will be off alignment to the globe (eyeball) and these realignments often take multiple surgeries to get the optimal result.

Once the horizontal level of the pupils differs by 5mms or more in eye asymmetry, attempts at surgical improvement are often met with mixed results and lead to multiple revisional procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had this horrible deep line between my brows that drives me insane. I recently tried Botox which I knew would not be a fix and I have contemplated fillers but I know fillers are not permanent. Words cannot express how I feel everyday about having this deep crease on my face. I have had side swept bangs for years and I’m tired of hiding behind my hair and wearing hats all the time. This is border line ruining my everyday life and has completely crushed my confidence. I took a few pictures for you to see my problem.

A: Thank you for sending your pictures. What you actually have are three distinct vertical glabellar lines, the central one is just the most deep. It is important to know that the ‘standard’ treatment would be a combination of Botox and injectable fillers. Botox to stop the cause (muscle movement) and injectable fillers to fill the defects. While this would definitely provide improvement it is probably not going to be a lifelong treatment strategy.On the opposite end of that approach is a surgical one with endoscopic muscle release and fat injections. In between the two lies the placement of a dermal fat graft or allogeneic dermis graft threaded into each one of the glabellar grooves.

As you can see the treatment of your glabellar lines is not an easy problem to solve. But at least there are a variety of different options to treat it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin implant replacement surgery or a double chin implant surgery. Hi I had read some of your articles and believe that you have much experience with chin implants. Would be grateful if you could respond my simple question, for which I can´t find any answer anywhere else. I have a Medpor chin implant (2 years ago) that isn´t big enough, and need a larger implant. If my surgeon don´t dare to remove the porex implant, is it possible to insert a new silicone chin implant over the Medpor implant? Would be so grateful for your answer!

A: While it is technically possible to place a silicone chin implant over your existing Medpor one, that would not be a good choice. There is a high risk of implant displacement and symmetry, not to mention the probably appearance of a ‘stacked’ look of two chin implants placed on top of each other. It would be far better to do a chin implant replacement approach, removing the Medpor implant and placing a new silicone chin implant that has all of the desired dimensions. (this may or may not require a custom chin implant given what have in and what the dimensions of your ultimate chin augmentation goals) Like all face and body implants the concept of stacking one implant on top of the other often leads to future problems. If your surgeon is unwilling or uncomfortable in removing a Medpor chin implant, you need to find a surgeon who has the experience in doing so. A one piece chin implant replacement is always going to be superior to trying to put two different chin implants together.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty for functional purposes. I am a 40 year old female with moderate obstructive sleep apnea with an AHI of 24 and 90% oxygen saturation at night while sleeping. I also have a very recessed chin and need a sliding genioplasty to both improve my obstructive sleep apnea and my cosmetic appearance. Maxillomandibular advancement osteotomies is not feasible for me. What type of sliding genioplasty is best, a mortisized genioplasty or a straight horizontal osteotomy? A craniofacial surgeon told me I need the mortisized type with a 4mm advancement.

A: I think what you are referring to is the difference between a straightforward sliding genioplasty and a ‘jumping’ genioplasty. I am not completely sure what you mean by a ‘mortisized genioplasty’ as that would refer to a bony genioglossus advancement only which would have no cosmetic benefit. That choice depends on which will give the greatest amount of chin advancement (which you need for your OSA) and what impact that would have on our appearance. With plate fixation the concept of a jumping sliding genioplasty has less significance than it did when only wire fixation was used. I would need to see pictures of your face and x-rays to best answer your question as to the optimal method of a sliding genioplasty for you.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reduction surgery. I am a 26 year old male and I am quite self conscious about my cheekbone width. They span almost 16cm and I am wandering if it would be possible to take about half a centimeter off on each side to make my eyes (pupilliary distance of about 65mm) more proportional to my face.

A: Your fundamental premise is that if the width of the face was less wide, your eyes would not look too close together. Since you can’t move your eyes this leaves only the cheekbone width to be changed. Cheekbone reduction surgery works by moving in the zygomatic arches of the zygomatic complex. These arches are what makes up the width of the middle part of the face. The inward movement of the cheeks usually is no greater than 5 to 7mms per side due to the location of the temporals muscle which lies underneath it. The bone should not ‘pinch’ the temporals muscle as this could interfere with the workings of it which is to help open and close the mouth.  Usually it is a good idea to get a 3D CT scan before cheekbone reduction surgery to look at the anatomy of the zygomatic arches and see how much reduction is possible.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about midface implants. A  maxillofacial surgeon recommended to me maxillary advancement to correct midface hypoplasia. Can you produce similar results through midface implants? 

A: The aesthetic benefits of onlay midface implants can rival if not be superior to maxillary advancement surgery. The only area in which the deficiency will remain is at the tooth or occlusal level as one’s bite will remain the same. Not changing the position of the anterior maxillary teeth does effect upper lip support and this is one aesthetic component of the midface which will not be improved by skeletal augmentation above it. Midface implants come in a wide variety of styles and sizes from the cheeks, infraorbital rims and tear trough, premaxillary-paranasal as well as maxillary implants. With the exception of the lower orbital rim implants, all midface implants are placed from incisions inside the mouth. Because of the location of midface implants on the side of the face, they are usually best secured with small titanium microscrews. When covering larger areas of the midface, it is often best to have custom midface implants made so that maximal midface augmentation in a smooth manner is achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I see you prefer to secure your chin implants with screws. I’ve searched all over my area for a doctor who does this and can’t find a single one. Do you know why this is? Is it inexperience? Is there some added risk of using screws of which I’m unaware? Do you ever do them without screw fixation? What about those who secure with sutures… what does that even mean? Thanks for your time.

A: Fixation of chin implants is done by various methods by different surgeons. By far the most common technique is the use of sutures where it is passed through the implant and done to the lining on or around the bone. One can have a debate about how secure this makes chin implants but this method highly depends on the size of the implant pocket to control asymmetry caused by a tilt in the left-to-right axis of the implant’s placement. Suture fixation can not control the potential for tilt from a single central point. Screw fixation is the most secure method and is really simple and quick to do…if one is familiar with doing it. Having done craniomaxillofacial surgery for decades this makes the use of screws for chin implants as familiar as using suture to close the wound.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, For midface augmentation, should I choose paranasal filler (my maxilla is quite forward, my midface is flat and doesn’t point forward as you see in my picture) and cheek filler, or should I get an implant? The second question: how do I change my eye shape? As you see, I got strong dark circles and they are round if you look from the front, do I need infraorbital rim implants to get rid of the circles and more almond eyes (this male model squint look) or can I use filler (upper eye lid for hood look and under the eye for the circles and almond look). Thanks and kind regards.

A: The use of injectable fillers, injectable fat or implants for midface augmentation are all  possible treatment options, each with their own well known advantages and disadvantages. But as a young person the best long-term approach is to have custom facial implants made for a permanent and more controlled facial shape change. Fillers and fat do not produce the same type of augmented facial look and are only going to be temporary. Eye shape change will require a lateral canthoplasty to deround the eye.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in removal surgery.  I was born with pectus excavatum and significant rib protrusion. I have been advised by a thoracic surgeon that the worst ribs are 7-9. The deformities seem to be limiting my lung expansion. My insurance will cover cosmetic procedures to correct congenital deformities, as well as, medically necessary procedures for respiratory issues. I have seen you write about providing a rib resection procedure for narrowing the appearance of one’s waistline. The thoracic surgeon indicated that there is a procedure for removing the ribs while leaving the lining intact so that new ribs can form hopefully more normally (sometimes requiring bracing). I would prefer to have a plastic surgeon do such a procedure to increase the likelihood of having a more aesthetically pleasing result. Therefore, my question is: Do you have experience with any rib removal procedures that would allow for rib regeneration, and if not, do you know of any other plastic surgeon that may?

A: Rib removal in an adult is a permament procedure. As an adult, ribs that are removed whether they be the bone or cartilaginous portion, will not regenerate. That ability is lost when one is older than one year of age. So your thoracic surgeon is either misinformed or you may not have understood fully what he/she was saying. More likely the thoracic surgeon was referring to rib reshaping. The proper treatment for a pectus excavatum deformity in an adult is known as a Nuss procedure. This is where a rigid bar is placed under the ribcage to push it outward and allow for expansion and some rib recontouring. For rib protrusions of the anterior subcostal margin (ribs 7 through 9) the cartilaginous portions of the ribs can be removed to lessen the visible portion. This will improve their appearance but will not provide any improvement in pulmonary function. Only a Nuss procedure can do that. Rib removal is a cosmetic procedure not a functional one. Loss of thoracic support from rib removal can not contribute to improved pulmonary function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions about faclal implants. Can cheek implants be done with local or non general anesthesia? Also I have a short face and need to add lateral width and height but I worry about the big wrap around jaw implants involving the masseter muscle. So can we do a custom chin implant with wide wings extending laterally and vertically as far back posteriorly as possible but not hitting the masseter muscle. I realize there would be a major step off somewhere further down the jaw and the rest all the way around the ramus I would fill in with fat or radiesse. Also could that be done without general anesthesia too?

A: In regards to facial implants, certainly cheek and an extended chin implant can be done under IV sedation or MAC. (monitored anesthesia care) The use of local anesthesia for most facial implants alone would likely be inadequate and that would be doubly true if both cheek and chin implants are done at the same time. Be aware that the use of local or IV sedation does not save any money as the intraoperative time to do facial implants takes twice as long as when done under general anesthesia. So your motivation for the selection of anesthesia for these facial implant surgeries should not be one of saving money.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants. I am a 29 year old female who has not had any children yet (would like to eventually), but has always wanted larger breasts. I am more than ready (financially and otherwise) to pursue surgery now, but am wondering if you recommend waiting until after pregnancy to have breast implants. Dies it matter having breast implants before or after pregnancy?

A: Your question about the timing of breast implants is a very good one for which there is no right or wrong answer. Unless one has a pregnancy planned in the near future, the placement of breast implants could be done at anytime. Unlike a tummy tuck, for example, pregnancy does not usually have a dramatic effect on the results of breast implants. Breast implants is also a self-image surgery so the timing of having that type of surgery is controlled by many personal factors, not a physical one per se. if you are psychologically and financially ready now, with no pressing plans for pregnancy in the foreseeable future, then placement of breast implants now is probably as good as anytime you may have for the rest of your life.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making my chin vertically longer.  I consulted a Oral and Maxillofacial Surgeon where he took x-rays and he said that I should probably do jaw surgery because he cannot do a sliding genioplasty of more than 3 mm without any hip bone grafts. Is this true? I definitely do not want to do a corrective jaw surgery because of the high risks. I would be okay with doing a sliding genioplasty but I am concerned with the involved hip procedure. Do you have pictures of patients who have had custom implants for the jaw and chin so i can see the results? Will they be similar results to someone doing a sliding genioplasty? Also how long is each of these procedures and recovery time?

A: It is absolutely not true that a vertical lengthening sliding genioplasty requires a bone graft. While a gap will be created between the two bony chin segments, the use of a  synthetic hydroxyapatite block works quite well as the interpositional graft. There is even some debate as to whether this bone gap needs to be treated at all. But certainly a bone graft is not needed in my experience. I have never placed a bone graft in the many vertical sliding genioplasties that I have done.

The vertically opening sliding genioplasty and a custom implant can have very similar effects. The only potential difference is at the jawline behind the chin and how well the bony genioplasty cut blends into it. But from the front view there would be no difference in the chin lengthening effect.

Both procedures requires several weeks for most of the swelling to go down. Recovery will also involve some temporary chin and lower lip numbness. (bony genioplasty only)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom jawline implant. I have a weak jawline. I have had braces in the past so I do not think it is related to an overbite. My face is vary narrow and I am hoping that I can add some lower jaw width. I really like that you are trained in maxillofacial surgery and your results are beautiful. I have attached some pictures and am open to suggestions and would like to get a quote. I have also attached photos of my aspired look. I look forward to hearing back from you!

A: Your face is narrow and your jawline or lower third of your face is your weakest skeletal feature. It is short in both jawline width and chin projection. The best method to achieve the ideal pictures you are demonstrating is through a custom jawline implant. That is the only method to get the desired facial width and have a smooth shape and transition from the chin back to the jaw angles. Standard chin and jaw angle implants are another option but are suboptimal as their effects will be a bit unconnected and not smooth…which is really crucial to the jawline look you desire. A custom jawline implant is the proven ideal method to improve the balance of the lower third of your face to what lies above it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have developed a neuroma after a facelift three years ago.I first noticed it when driving and my shirt collar rubbed against it and it felt as though there was something tickling my right ear.  The surgeon treated the neuroma with a steroid shot.  Although the numbness and sensitivity went down it was still there.  The doctor treated the neuroma two more times without improvement. The numbness extends along my lower right jaw line, upper right neck, right cheek in front of the right ear and the right ear. My surgeon told me he never had a patient with a neuroma that was not treated successfully by injecting a steroid.

I visited another facial surgeon earlier this year. He told me if he did the facial surgery he would recommend treating the neuroma at that time as another facelift.  He said he would cut the neuroma off/away from the nerve. He said it might not correct the problem completely and that I might have complete numbness in some of the areas where I now I have this strange feeling in my face.   

I am reluctant to have either surgeon cut me since neither has treated a neuroma before.  I would appreciate your recommendation concerning my neuroma at this time.

A: Thank you for the detailed descriptions of your after facelift issues. I can make the following comments.

1) While steroids is not an unreasonable approach to an initial treatment of a neuroma, when refractory, others more definitive approaches need to be considered.

2) I have not had a patient develop a neuroma of the greater auricular nerve after a facelift but I have treated several that have.

3) The traditional treatment of a neuroma would be excision and burying the ends of the nerve into the muscle. It is possible, although less likely, that the entrapped portion of the nerve could be identified, excised and the nerve repaired by putting the two ends back together. This would be dependent on being able to find the actual location of the neuroma amidst scar tissue which is usually possible because it is so superficial and its location can be identified externally before the surgery.

4) What will happen to the sensory innervation after any of these possible neuroma treatments is unpredictable…meaning it may get better worse or there be no change. Bring three years out of the procedure makes it a different situation than when done much earlier. Similarly the impact of the neuroma repair plus or minus facelift in your tinnitus is similarly a wild card. Getting it or its exacerbation from a facelift was not a predictable event so what happens with further surgery should not be assumed.

5) Whether you treat the neuroma independent on a facelift or at the same time is personal decision and depends on your motivation for a secondary facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you have performed this type of skull reduction surgery before. I have a very pronounced bump on the top of my head near the back as you can see. I would like to have the spot reduced down to make my head shape a little rounder. I am also wondering what kind of scarring I will have afterwards? I am bald so minimal scarring procedures would be the best option for me. If you could also give me a rough estimate of the cost that would be great.

A: Sagittal crest skull reduction is a procedure that I have done numerous times. Your situation is exactly the type of patient in which this type of skull reduction is done….male, shaved head, and a posterior raised end of the sagittal crest. This is done through a small curved 4.5 cm incision. From this limited incision as much bone is reduced as possible. I have always been impressed with how well this incision heals and how imperceptible it can be later. On average the total cost of the surgery is around  $ 6,500. Most patients can achieve a near complete flattening of the raised area with sagittal crest skull reduction surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read one of your posts about reversing cheek dimple surgery and I would like to set up a consultation with you. I had cheek dimple surgery on my left smile groove about 2 years ago. The day after the surgery I knew it was a mistake and asked the surgeon to undo the dimple. He loosened the suture but since then the dimple is still there. It was suggested that I do a subcision and I have had a total of 3 subcisions in the same area but now I have a donut-like shape to it whenever I smile. I also have a hard bump underneath the dimple that may be contributing to the donut-shape (I’m thinking this may be scar tissue from the subcision). I would like to fix the donut shape and to get my natural face back. Would this be something you would do in your office? 

A: Most cheek simple surgery procedures have the problem of being unable to sustain their effect and the result is less than some patients want. Your problem is unusual in my experience in that a cheek dimple surgery undone the next day has resulted in a permanent indentation. Subcision early after the procedure was certainly a reasonable approach. But now at two years after the procedure, it is going to take more than that to create improvement in the cheek indentation. Your cheek dimple reversal surgery is going to require a fat graft either through injection or placement of a dermal-fat graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I was wondering if you did the ‘chin wing osteotomy’ surgery which is different from a genioplasty where they move the jaw forward ? I saw your response to someone else asking the same question on Real Self and you said you’ve done it before and I was interested. Not a genioplasty or a chin implant which I can get done where I live.  I’m not sure if there’s other names for it but that’s what it’s called on other surgeons websites who do it. I’m assuming it’s called a chin wing osteotomy.

A: I am very familiar with the chin wing osteotomy, having performed it numerous times. Quite frankly I think it is not a very good procedure for the problem that it is designed to treat. It is technically difficult to perform and is prone to a high rate of complications. Iy requires a long bony cut back from the chin to the jaw angles underneath the mental nerve foramen and the path of the inferior alveolar bone as it courses through the bone.

It is really an historic procedure for which there are more effective procedures today. It is far easier, has less complications and a better result is obtained using a custom made jawline implant when attempting to obtained total vertical jawline augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a more elongated lower 3rd of my face with less of a square look. I previously had liposuction done underneath my chin but it has never improved. Will the chin augmentation improve this area? Also, approximately how much length in mm is needed to achieve what I am looking for? Thank you!

A: You have a very distinct chin augmentation need. Your square jawline and distance between the base of the nose and the chin indicates that there is a vertical lower facial deficiency. I would not have expected liposuction under the chin to change what is a skeletal issue. There are twi fundamental approaches to managing a vertical lower third of the face deficiency. If it is just located anteriorly a vertical lengthening sliding genioplasty or a custom vertical lengthening chin implant can be used. If one feels the entire jawline is vertically short from front to back only a custom jawline implant that lengthens the entire jawline can be done. In looking at your face my feeling is that a vertical lengthening sliding genioplasty would probably be the best choice. In my experience at least a 7mm vertical increase is usually needed to make a noticeable vertical chin augmentation change. This is done by an open wedge bony genioplasty where the front edge if the bone rotate down while the back edge of the bony cut keeps the bone in the same position. The exact measurement of vertical chin lengthening needed can also be determined by two other methods. One can open their lower jaw to the vertical chin length that looks good to you and measure the created distance between the front teeth. One can also take measurements of their facial thirds and then see how short in millimeters the lower facial third is. I would do both methods to see how well they correlate so you can select the most effective vertical chin augmentation improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I spoke to you this last summer on Skype regarding forehead augmentation. I  favor using bone cement as opposed to a silicone implant. Do you think burring of my supraorbital ridge will be necessary? If so, would the charge me extra? and is there a risk of damage to my sinus cavity?

A: When you have the severely sloped forehead that you have, it would be good to to do some modest burring of the supraorbital ridge. It would be complementary to the forehead augmentation in creating a better overall result. With burring the key is to stay out of the frontal sinus which requires experience in doing so. How much reduction can be obtained is a function of the thickness of your frontal sinus wall. If you need a frontal sinus setback that would be important to know up front because it will take some more surgical time to do and there will be some extra costs in doing so.

The choice of forehead augmentation material is a personal one. I have used both bone cements and custom implants successfully and each has their own advantages and disadvantages. I do not necessarily favor one over the other, I just try and educate the patient on the merits of each material.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a corner of mouth lift. I have had fillers and Dysport to lift the corners of my mouth. I don’t believe the doctor who did my filler placed it right. I have a puffy place then it goes flat and it didn’t raise the corners of my mouth at all. I spent a lot of money to get that done. I was wondering if you think a corner of the mouth lift would help and how much does it cost. I am 48 years old. Thank you.

A: While injectable fillers and neuromuscular modulators can have a positive effect on the corner of the mouth, it depends on what the original problem was (how severe is the corner of the mouth droop) and what type of change (corner of mouth lift) one was looking to achieve. Your result may be a function of an incorrect treatment for the problem (mouth corners to severely sagged) or the correct treatment that was not ideally done. I can not say which led to your post-treatment results. I would need to see pictures of your mouth area to determine what is the best approach now.

What I can say is that a corner of mouth lift is the single most effective method for changing the shape of the corners of the mouth that produces a more profound and sustained result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin ptosis repair surgery. I am emailing you to see if you are able to correct my chin deformity from a previous surgery five years ago. I had a chin implant removed from twenty five years ago because it made my chin look very wide and bulky. The surgeon performed a sliding genioplasty for a 3mm advancement and a lipectomy which left me with a depression and a bulge. I now have redundant skin hanging and my chin is very flat and wide and misshapen. If there is anything you think you can do to correct this please let me know.

A: Thank you for sending your pictures. What you have is chin ptosis and a residual wide chin. (since I do not know what you looked like before I can only go by your current picture) The best approach for your chin ptosis repair is a submental chin reshaping procedure to taper your bony chin and get rid of the overhanging tissue. This is the most assured way to get a better chin contour by dealing with both the bony and soft tissue components of the problem from the underside of the chin. As your chin problem is primarily that of loose skin this is particularly the best chin ptosis repair approach for you.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a full tummy tuck. I believe I would accept the trade off of the scar for the results of the tummy tuck. My loose skin bothers me so much I do not take my shirt off in front of anyone and I will not wear a bathing suit. I find myself covering my stomach with my arm even when I am alone. It would ultimately depend on how high the incision would be and how inconspicuous it would be over time. I have researched hundreds of before and after photos on real self and women with similar “before” photos like my stomach and was very impressed with the results. With my C-section incision, my appendectomy incisions and all the stretch marks from pregnancy I think the incision would be a fair trade. Again, I would want to know where the incision would be and I know that could only be accomplished through an in-person consultation.

I am slightly concerned about the nipple lift for my breast augmentation. I am not sure what that entails, but it makes me more nervous than the tummy tuck incision. I am most concerned of lost sensation and additional scarring as a result.

A: You have made a key point in understanding the aesthetic trade-offs of many cosmetic procedures, particularly that of a tummy tuck. Each option (keeping your loose abdominal skin vs a tummy tuck) is not perfect and you choose which ‘problem’ you can live with the best. The tummy tuck scar will not end up as low as your c-section scar and will probably end up 1 to 2 inches higher. Also it would be likely that our full tummy tuck scar will end up with a small midline vertical component running just above the horizontal part of the incision. This is sometimes necessary when doing a full tummy tuck to keep the central aspect of the scar low rather than being pulled up in the middle. While many tummy tuck scars do heal well, I don’t think I would ever call them inconspicuous but that is a matter of personal perspective.

The small nipple lift scars are really irrelevant and are not a concern for visibility or nipple sensation. The choice you will have to make is that your nipples may not be centered on your breast mound without them given your existing breast sagging. It is important to understand that implants do not create a lifting effect on the breasts. They merely make breasts bigger and can magnify any existing breast asymmetry or breast sagging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some type of shoulder implants. I want to correct my body shape. All of the doctors I have seen suggest liposuction from belly and then inject that fat to shoulder areas but I think this is temporary solution. I dream something like silicone implants which are created custom for me. Please check my before and after photos I made it on an app.

A: What you seek for shoulder implants does exist and they are known as deltoid implants. Shoulder widening surgery can be done using preformed body implants or they can be custom made from a low durometer (very soft) solid silicone material. They are inserted from an incision at the back end of the armpit skin crease. Since there are no performed or standard deltoid implants, preformed calf implants are often used for the deltoid area as they have a long cylindrical shape to cover the central deltoid muscle. Custom shoulder implants can also be made from measurements on the patient baed on their length and width of the central deltoid muscle. Shoulder implant surgery is a procedure that takes about 90 minutes to perform under general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in vermilion border advancement (lip advancement) in the sides/ corners of my upper and lower lips. I would also like to pair this with large permalip implants. I have several questions. Can these two procedures be done at the same time? What would the down time be? What is the cost? Finally, I am not looking for a “natural look”. I have had my lips quite full using injections for several years and like this look but do not enjoy the costly upkeep since they wear off in two to three months in my lips. I can pictures of my lips without injections and a photo of what I want to achieve to see if you think it is achievable using the Permalip implants and vermilion border advancement in the sides/ corners. Thanks! 

A: Your description of the lip procedures you would need to achieve your goals is correct. It would be necessary to do an upper lip[ advancement but spare the central cupid’s bow area. Permalip implants could be placed at the same time as the lip advancements. As you might image there will be some considerable lip swelling that will take several weeks to subside but that is more of a social issue not a physical limiting one from a recovery standpoint.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty revision. I am a young male who underwent a sliding genioplasty six months ago to fix some minor facial asymmetry. The idea was to move the chin 1to 2 mms upward and 3 to 4 mms forward. Unfortunately, this didn’t happen. Instead, the right side was moved according to plan, but the left side wasn’t causing it to be rotated outwards and downwards. My chin is now crooked with the left side being considerably fuller both laterally and anteriorly, but also vertically longer (aproximately 5 mm height difference).

I’ve met with a new surgeon in order to try to get this corrected. He suggested an intra-oral burring of the bigger side (left) in order to spare me a scar. He said he would be able to reduce the height too. I did some research and it seems to be quite tricky to do an intra-oral burring for vertical reduction? I know you prefer the submental approach, but I’d like to hear your views on doing this intra-orally. Can the inferior border really be reached? How many millimeters can usually be removed vertically using the intraoral approach? And what are the chances of tissue sagging?

A:You are correct in assuming that it can be both difficult and unpredictable attempting to make these modifications through an intraoral approach. It would be simpler, more predictable and have lower risks of tissue sagging if it was done from a small submental incision. Seems like a difficult approach that has limitations when you are trying to fine tune the chin bone shape. You have already learned the lesson that when doing minor aesthetic corrections it is easy to miss the mark and still have residual issues. Any further revisions should be done with the technique that would be most likely to reach your goal with a low risk of further aesthetic issues.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in revision of an otoplasty reversal procedure that I had just a few weeks ago. I had an otoplasty twenty years ago where the ears were over corrected and pulled back too far. I had an otoplasty reversal done two weeks ago to project the ears further out from my head. When i left the doctors office they looked great but with in five days the results were back to the same as before surgery and is still changing. Is there anything i can do to correct and regain the result of a few weeks ago. What my options? Thank you.

A: In otoplasty reversal surgery for the classic telephone ear deformity that you have, the key surgical maneuver is to place an interpositional spacer or graft once the overfolded ear cartilage is released. If this is not done the procedure will not work. It may look good for a few days because of swelling and the local anesthetic injected into it but cartilage release alone will return quite quickly back to where you started. That will only work if the otoplasty is new and within a few months after the initial surgery. Once the cartilage is released something must hold it out to occupy the open space between the ear folds to not only overcome the ear cartilage memory but to prevent scar contracture pulling the ear right back into the overfolded position. I have used a lot of different material for the procedures but my current favorite is irradiated homologous rib graft. It is very sturdy and avoids any rib graft harvest from the patient.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry correction. My son was born with torticollis. He had physical therapy for a few years but he still is self conscious about his eyes and the fact that his nose and chin don’t align. Is this something that you could improve?

A: It can be seen that he has right sided facial shortening type facial asymmetry. The vertical length of his right face from eyebrow to chin is shorter than the left side. As a result there is a deviation of twisting of the face to his right. Because of his congenital torticollis he may or may not have a chronic head tilt to the left side. My comments will be based on that he does not.

The top and bottom of the vertical facial axis is the key. A right endoscopic browlift with upper blepharoplasty (to create a visible supratarsal fold like the left side) is what is needed superiorly. Inferiorly the chin need to be rotated over to the left with a vertical opening wedge on the right to straighten and lengthen it. I think these would be the two key areas to improve for his facial asymmetry surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get orbital rim implants to correct my negative vector (it bothers me a lot), and being that it’s an obscure procedure (I’ve only found you and one other doctor that performs it), my biggest concern is the implants’ safety, considering their proximity to the eyeball, and chance of migration. I also wanted to correct a nasal tip deformity that happened as a result of an initial rhinoplasty five years ago. Thank you, Doctor.

A: Orbital rim implants are one of the most uncommon facial implants as there are no preformed implants for this facial skeletal area. The best way to create orbital rim implants is to have them made in a custom fashion for each patient off of a 3D CT scan. That way they will fit the bone precisely which, when combined with microscrew fixation, assures their long-term stability. These implants are very safe and pose no threat to the eye when out in by a surgeon skilled in working in this area. Orbital rim implants are very effective at achieving exactly your concern…eliminating tear troughs and a negative orbital vector.

As for your nose, what I see is an entire deviated nasal axis to the right and tip cartilages that deviate to the left. The deviation appears to not be just restricted to the tip of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an ethnic rhinoplasty question. Is there a medical term for putting a building block or supporting structure under the nose tip if you don’t have much under there? (i.e such as that in Asian and African American noses)  I thought it was a nasal strut but I don’t think that is it because that is only used when someone’s nose tip is drooping. Would a nasal strut make someone’s nose more turned up than it already is?  Mine is already turned up.  I am just asking because I am trying to figure out exactly what I need before I do anything. Thanks.

A: Your question appears to relate specifically to ethnic rhinoplasty. What you refer to as a nasal strut is more specifically called a columellar strut. This is a vertical strut of cartilage placed between the base of the nose up to the tip between the medial footplates of the lower alar cartilages. This is a very versatile support graft that can be used for a variety of nasal reshaping. purposes such as long-term support to prevent tip collapse/rounding to being long enough to increase actual nasal tip projection.

The use of a columellar strut is of critical importance in just about every Asian and African-American ethic rhinoplasty to change the rounded tip of the nose to a more narrow one with better definition. It is not the only rhinoplasty maneuver done to create that effect but it would be considered the ‘building block’ of the tip of the nose. A columellar strut, in and of itself, will not necessarily increase nasal tip projection. When combined with a variety of other cartilage grafts (e.g., septal extension graft) it may even be used to decrease tip projection while also making the nasal tip less wide and more defined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, This is a strange question but is it possible to get donor grafts from the part of the head that isn’t considered a donor area? I know your average person has around 8K hair grafts available from the DONOR area, but if someone wanted to access the grafts from the other areas, would this be technically possible?  

Say there was a person that wanted a significant beard transplant and this person was much taller than the vast majority of people. They would prefer to take grafts from the non donor areas of their head because they are much taller than everyone around them, they would like to be able to conceal their scar or FUE procedure more effectively since very few people would see the top of their heads. They understand that FUT and FUE procedures nowadays can go undetected with good scar rejuvenation but still they would rather have the scars placed in a more undetectable area. They completely understand that non donor areas are labeled such because there is the risk that they will dissipate with progressive male hair pattern baldness and they are completely aware of this risk because they are already on balding medications such as finasteride and have no significant history of baldness in the family.

Would a situation like this be reason enough to oblige to their request of taking hairs from where they want:non donor area on top of head? or is there some physical reason why something like this may not be possible.

A: The simple answer to your question is that there is not a technical reason that the harvest site for hair transplants can not be taken from anywhere on the head. The reason the back of the head is used is two-fold; that is where most of the available hair is and it is hair that is theoretically programmed to last a lifetime for many men.

Dr. Barry Eppley

Indianapolis, Indiana