Your Questions
Your Questions
Q: Dr. Eppley, I am interested in skull reshaping surgery. But I am very discouraged from moving forward with what we have discussed so far because when I look in the mirror and I see the flaws I have and how it bothers me and why it bothers me, it leads me to believe that I would feel the same way with these proposed minor changes we discussed previously. I wholeheartedly believe for me to be actually satisfied with an end result I would have to move forward with the FULL correction of skull irregularities which I am aware will result in a scar over my head from ear to ear. I am one of those individuals with an OCD personality so I know for sure that i should either go all the way or not at all because in the end it wouldn’t truly make me happy looking in the mirror and still seeing asymmetrical skull features. My whole purpose of coming to you is because I am extremely self aware of my asymmetry in my skull, the bulge on the one side of my head drives me insane and you have already made it clear you cannot work on that unless you open up my skull side to side so that is why I am leaning toward going all the way and reshaping the whole skull. I have attached a picture of a professional athlete who has what appears to be a coronal scalp scar.
A: You are indeed looking at a rare near total coronal incision on a shaved head. I do not know why that person had that operation but that scar from your perspective is helpful. That scar location on the scalp is not exactly were such an incision would be placed on you. It would be placed further back and and would to be in a completely straight line from side to side. It would be more curved but would probably go no lower in the temples than what is shown in his pictures. I would consider his scar width to be the absolute worst case scenario as it is fairly wide by my standards. I believe your scar width would be much better than that one.
But this person’s scalp scar serves a very valuable purpose. if you can look at that scar and say that it would be preferred to your skull shape issues, then it is a ‘safe’ aesthetic skull reshaping operation for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a z-plasty for a neck deformity that is present in Turner Syndrome. (webbed neck correction) Is this a procedure that can be performed? I’m 38 years old. I have never been diagnosed with Turner Syndrome, but I have also never been tested. I highly suspect that I have Mosaic Turner’s Syndrome as I have neck webs. I’m not only interested in its cosmetic improvement, but also improved function.
A: Thank you for inquiry and sending your neck picture. While you may have never been diagnosed or tested for Turner’s syndrome (and I am not saying you may have it), you definitely have neck webbing. It may not be as severe as in the cases of Turner’s syndrome that I have treated, but they are definitely present. Your neck webs can be improved/eliminated through a geometric tissue rearrangement technique on the back of the neck and up into the hairline. No incisions or scars are placed along the visible web lines as has been classically described in the past. This type of webbed neck correction surgery improves its cosmetic appearance but has no known functional benefit. It will not make the neck move any better or improve its range of motion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a Custom Jaw Implant for a stronger more chiseled jawline, however the barrier which is holding me back seems to be concern over the infection rate. I recently had a consult with a respected surgeon in this field who prefers Medpor over Silicone, and I’ve read a few posts online from people who claim they have knowledge in this area saying Medpor achieves a more chiseled bone-like look when compared to Silicone. Personally I’m against the idea of having something so nasty to remove, so my question really is can Silicone match Medpor in it’s ability to produce natural bone-like look?
I’ve seen a few jawline implant results in the UK, all using Silicone and all end up looking sub-par, ending with a larger jawline but not a better looking one (a blockhead type look). Though I assume some of this is down to the surgeons lack of experience and the implant design, having a chiseled end result is very important to me hence the concern over the implants ability to give this.
Back to my initial problem with infection rates, how common a problem is this and if one does have an infection how easy is it to replace the implant and start over?
A: Thank you for your inquiry about a custom jaw implant. In answer to your questions about any type of jaw implant, but particularly that of a custom design:
- There is no one material advantage over another when it comes to creating an external effect. That would make no biologic sense at all. It is all about the design of the implant, just like it would be anywhere else on the face or the body. The implant’s shape and dimensions, and its push on the overlying tissues, controls any external effect. Thus there is no difference in whether the implant is composed of Medpor or Silicone. Any surgeon or anyone else that says so simply does not know of what they speak.
- Beyond its design, the effect of a custom jaw implant is also heavily influenced by the thickness of the soft tissues which sit on top of it. You can not take a fuller, thicker-skinned face and give it a well-defined and angular jawline. The thicker facial tissues simply won’t permit that effect to be seen. When trying to do so with any implant, all that will happen is that the patient’s face will just get bigger and fuller. The patients that get the best jawline results have thinner faces where a proper design, even if it is not particularly big, shows through the tissues.
- Like any other surgery that is technically challenging, the design and proper placement of a custom jawline implant is not easy. It is not something that a surgeon does once a year and gets any good at it. I have done hundreds of them and I keep learning both design and technical lessons from just about each case. The learning curve is very steep with this type of facial surgery.
- In my experience the infection rates with Medpor have always been higher than silicone because it has an irregular surface that can hold on to bacteria more easily. (cellular adhesion) But an infected implant, regardless of its composition, is easier to remove than one that isn’t. It is the Medpor implant that is not infected that is the challenge and the number of patients who request removal or removal/replacement for aesthetic reasons occurs 10X more frequently than infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about non-surgical breast enlargement. I have read several articles about a strip tease artist from the early nineteen sixties who was born a man. His / her stage name was ” Alexandra, the Great 48 “. His birth name was Gary Paradis. 48 stood for the size of her breasts.
A book ” I Want To Be A Woman ” was published in 1964 recounting her journey from a man to a woman. In the book, she states that she obtained her fantastic bust by applying estrogen or progesterone creams to her breasts. I have always read that these hormonal creams are ineffective.
What is your opinion about non-surgical breast enlargement with hormone creams?
A: Having seen pictures of her and knowing that she was originally a man, my opinion would be that her breast size would be impossible to obtain by any form of topical hormonal creams.
Topical hormones work to stimulate existing breast tissue. While some breast size change may be possible, the amount of breast augmentation would be limited in a genetic male who is trying to grow breasts. This is fairly well known by the more common scenario today of transgender females taking oral and even implanted hormones with only very modest non-surgical breast enlargement results. Toping dosing would be far less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. I had a rhinoplasty in Mexico three years ago. I saw a picture from the surgeon that had done an ethnic rhinoplasty on an African American female’s nose that had features similar to mine. I liked that that tip was not pinched or raised or triangular like Michael Jackson’s nose. We agreed that he would not touch the tip or lift the tip. Afterward no stitches or cut to the nostrils was seen but there was increased nostril show to my surprise and my tip was smaller. My entire nose was lifted and I now feel a nose bone which I’m almost certain I did not feel before. Another plastic sugeon said my nose has been changed. She said once the nose is lifted it can’t go back down. But I’m wondering is there a way to fill out tip, minimize the nostril show, and widen the nostrils again maybe with a filler?
A big problem that I have is that I can see my columella. In a before picture of my nose I see no collumella. My long time best friend, whom I’ve not confided in, said she almost didn’t recognize me. People kept saying who is that. Also the upper part of nose is high now and there is increased height now from top of bridge to top of nose. My nose is standing higher now and the tip is pinched 😪
Is it possible to revise this nose to look more like my old nose?
A: Thank you for providing some of the specifics of rhinoplasty. What counts is what you see now versus what your nose used to look like. It appears by your pictures and description that you had a nasal implant placed. (it is not a bone but an implant) By removing the implant your nasal bridge will go down as much as the size of the implant which should take that part of your nose back to the way it was.
For the tip, cartilage grafts can be used to widen the tip, provide increased support to your nostrils and bring down the tip again. The key is the cartilage graft to do it as enough material is needed to do an adequate job. You have three choices for the cartilage grafts; 1) septum and ears, 2) your own rib, or 3) use of cadaveric rib grafts.
While getting you back to your exact preoperative nose shape may not be completely achievable with any form of revision rhinoplasty, I think you could go a long way to getting a nose shape that is much more like you used to be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting tear trough implants. Whenever you have the time, I wrote down a few questions for you:
-In regards to affecting vision when working in the lower eye area, my understanding is that there have been issues with injectable fillers/fat injections very rarely being injecting into veins and causing an retinal artery occlusion. Since this is an implant, is it safe to assume this is not an issue to be concerned with, and that vision will not be affected? Is there a concern with the pressure of the implant against veins or nerves in the lower eyelid area?
-I have some reservations about doing an eyelid incision, would tear trough implants or submalar implants be able to be inserted through the mouth as an alternative to improve the upper cheek area/lower eyelid area?
-Is there irritation in the eye area during the recovery time for the eyelid incision?
-Is the implant shown made from silicone? I would prefer to use that material rather than Med-por since I already have silicone used for the skull implants and seem to be doing very well with those.
-Are there medical complications if I ever decide to have the implant removed?
A: In answer to your tear trough implants questions:
1) Placement of infraorbital rim-malar implants does not affect vision or poses any risk to it. There is also no issues with adverse pressure on any neurovascular structures in the area.
2) You can placed infraorbital-malar implants through the mouth but there is a higher risk of implant malposition and there would be some protracted numbness of the lip and nose because of traction on the infraorbital nerve. These potential issues are mitigated when going through lower eyelid incisions.
3) These would be silicone implants.
4) There are no medical complications from removing such implants later if so desired. In fact they are less traumatic to remove than they are to place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe my 6 week old son has Stahl’s ear, one ear looks worse than the other. I found you listed as a Dr familiar with the Earwell system of molding the ear without surgery. I would like more information on this treatment and wondered if we would need a referral by his pediatrician. Thank you!
A: The treatment of the Stahl’s ear is of the congenital ear deformities that the Earwell system can successfully treated provided certain criteria are met. The most important criteria is the initiation of early treatment. The sooner after birth the Earwell devices are applied the better the molding results will be. After the first month of life the maternal estrogens drop precipitously and the hyaline cartilage of the ear begins to stiffen. Once the ear cartilage starts to get stiffer it becomes more resistant to external molding forces. (its ‘memory’ improves) After 6 to 8 weeks after birth the success of the Earwell drops consderably.
One does not need a pediatrician referral to have the treatment. You just need to find an Earwell provider and contact them directly. Going through the internet is both how you will find a provider as well as making contact to get started as soon as you can.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring as to whether you do chin implant removal. I found you by searching the internet and then watched some of your videos. I had a chin implant in Dec. 2003. It changed the way my smile looks for the worse. I am hoping to have it removed or “trimmed” down. I would prefer to have it completely removed. The Dr. did a great job – but I had no idea that it would not result in this change in my smile and as a result the lower part of my face looks odd and out of proportion when I smile. Thank you for any advice or help.
A: Chin implants can be removed just as easily as they were put in. Whether your implant should be completely removed or made smaller is really a function of what you want to achieve. Keep some of its aesthetic benefits but hope that it improves the way your face looks when you smile….or just remove it as it no longer has any aesthetic value for you. The other issue is whether you would develop any chin ptosis with its removal that needs to be simultaneously managed/prevented. This would depend on the size of your chin implant, what material it is composed of (Medpor vs silicone) and what you look like now. I would need to see some pictures of your face, smiling and non-smiling, to provide any further insight.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a custom jaw and cheek implants. However, I have already had jaw and cheek implants inserted around 4 years ago now. I wasn’t completely satisfied with the results and so thought custom implants would be a better option. My question is, can you still make custom implants for someone with the same accuracy if they already have implants in place? I believe you use a 3D CT scan to base the custom implant on, but will this work for patients with existing implants in place?
A: It may surprise you to know that it is very common to make custom jaw and cheek implants in patients who have existing standard implants in place. Having existing jaw or cheek implants, or any facial implant for that mna in place does not interfere with the visualization of the natural bone or the accuracy of making custom implants on that bone. For the design process the existing implants are digitally removed. Actually having implants in place is very helpful for the new design as those dimensions provide a guide as to how much bigger or smaller the new implant dimensions should be and where any changes are desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an injectable cranioplasty procedure done last year by another doctor. The results were less than stellar. The size is small, approx 1″ x 3/4″. I have the following questions:
1) is it possible to burr the implant down through the original 1/2″ incision
2) will the rasping damage the hairs above the site
3) is there risk of cracking the implant
Thanks in advance for your response.
A: An Injectable cranioplasty, even when small, is prone to irregularities and edging. It takes a lot of practice and negative outcomes to work the kinks out of this procedure because it is done in a blind fashion. What material was injected? (I will assume PMMA)
In answer to your questions:
1) It is not possible too smooth out the material through the small incision by which it was placed. That is the downside to an injectable cranioplasty. If the result isn’t perfectly smooth the incision will have to be enlarged to modify/remove it.
2) If it is PMMA or even hydroxyapatite (HA), you can not rasp it or smooth it. PMMA is too hard and HA is too brittle for rasping. They have to be burred down for further contouring. In many cases, you are better off removing it and replacing it.
3) The implant will fracture/crack with any type of closed manipulation such as rasping or burring.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wanting to get a post tragal incision from a facelift reversed to create the incision in front of my ear to re-expose more of my ear. Can this be done?
A:Thank you for sending the excellent pictures which show the transposition of facial skin up onto the tragus of the ear from your facelift surgery. It is easy to see the very dramatic difference between the thinner skin of the ear and the thicker hair-bearing skin of the face. This has resulted in loss of the ear-facial skin demarcation as well as the natural buffer of non-hair bearing skin in front of the ear. You can not really reverse the effects of the facelift on the ear per se as the natural tragal skin has been removed during the facelift and replaced with the facial skin flap. All you could do is remove the facial skin from the tragus and replace it with a full-thickness skin graft from the back to the ear. Whether this would be considered an improvement is open to debate as this has the potential to create a bit of a patch-like appearance based on how the skin graft heals. It may also look fine but it is all in how the skin graft heals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the jaw reduction surgery.This surgery is not very much performed in the USA as you probably know. I feel like I have a wide face. My main concern is my jaw angle and my jaw and chin area giving it a broad, masculine look. One doctor also recommended that I get cheekbone reduction as well and possibly rhinoplasty. I would look to know your professional opinion please since you have experience and great credentials. Here are a few pictures. Thanks!
A: Thank you for sending pictures. Your interest in jaw reduction surgery stems from the observation that you have a flat or near zero mandibular plane angle. This means that the length of your jaw angles is nearly the same as the vertical length of your chin, thus giving you a square facial shape. To give you a more pleasing mandibular plane angle and less square of a facial shape the ideal approach is a combination of vertical reduction of the jaw angles and a vertical chin lengthening. By shortening the back part of the jaw and lengthening your chin, your mandibular plane angle will become more steep and your facial shape will be more oval. The bone removed from the jaw angles could be used as an interposition graft for the vertical chin lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a browlift after having a browlift. I had some injectable filler placed into my forehead and, because I did not like the result, I have it reversed by hyaluronidase injections. NowI think the skin has probably been stretched a bit by the product, making my brows lower.
In light of this, I’ve started considering a browlift. I’d actually considered a subtle one before all of this anyway, but didn’t think I’d need it so soon. My question is, how would the skull implant affect the browlift? Would it make it hard to do? I am quite serious about this, so if you could share your thoughts I would really appreciate it!
A; When it comes to a browift, it depends on what technique you are contemplating as to how your current skull implant would effect the result or whether such a browlift can even be done. The one type of browlift that can not be done is an endoscopic technique. The endoscopic method depends on an epicranial shift which would now be impossible given that there is a skull implant in place. An excisional technique s possible using either your existing scalp incision or a hairline or pretrichial technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in reversal jaw reduction surgery. I used to have a very strong square jaw, and last year I went and had a sliding genoplasty to add some shape to my face. The surgeon suggested that I should shave down my jaw angles a little to elongate my chin without increasing the vertical projection too much as it would make my face look too long for my body. However, they went completely overboard and shaved down so much of my jaw that I now have an oval face, which I am not happy with. I am looking to put in a jaw angle implant to bring back some definition.
A: I would need to see some pictures of your face for my assessment and recommendations. If you have any before pictures prior to your last surgery that would be very helpful as well. The typical treatment for overzealous jaw angle reduction would be vertical lengthening jaw angle implants to create a reversal jaw angle surgery effect. Because very few jaw angle reductions are symmetric, there are can be a role for custom jaw angle implants as opposed to standard shapes depending upon that degree of jaw asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a recent recipient of a skin only lip lift, from another doctor. Unfortunately the top lip I was left with a triangular in shape and overly close to my nose (about 7-8mm). I was told that the doctor removed about 8-9mm of skin. I’m mortified. It looks very unnatural and I am so unhappy now. I’m only 27 and terrified to think that I might have to live the rest of my life looking like this! I saw a post on real self from a girl in a similar situation, to which you commented that it would be possible to reverse the lip lift by performing a Y-V? Would this be something that can potentially help me? I’m assuming this could lower the Cupid’s bow 4-5mm so that it looks more natural? No other surgeons that I’ve reached out to are willing to help. Please let me know if you can help me.
A: A subnasal lip lift that removes over 50% of the vertical distance between the lip and nose will likely end up with an overdone result…which appears as a triangular shape to the upper lip with an inverted smile line. You did not say how long along this lip procedure was done but I assume it was fairly recent. It is important to know that all subnasal lip lifts do relax in the first three to six months after the procedure. That relapse (due to lip stretching) can be as much as 25%, so some improvement will naturally occur.
A V-Y lip advancement is an internal mucosal procedure designed to lengthen the upper lip smile line (drop down the vermilion) That can be effective is some overdone lip lift cases. The outward vertical sin distance can only be increased by skin grafting which would create an unnatural patch of skin so this is not advised.
I would need to see a picture of your upper lip yo provide a more qualified answer as to what and is not possible your current situation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. I did my first rhinoplasty surgery because I didn’t like my nose tip it was a little bit to large for my nose, but that was the only aspect of my nose that I disliked and wanted changed. The doctor said that he could make the tip a little bit less large but he also said that he would need to take 1 mm of my nose bridge to take the hump out (that I didn’t have too much) and with that my tip would be raised 1 mm too because he would change my hump I asked him to just do the tip but he said that it would be better. So I agreed, but after my surgery I noticed that he took way more then 1mm of my bridge and raised way too much my tip. Now my nose has a C shape and my tip is too high. I want my bridge raised again to the previous shape and to add more length to my nose as it was before the surgery. Would that be possible? I don’t think that my tip needs anymore change I was want it to look less upturned.Thank you so much in advance. Please see the pictures attached.
A: Thank you for sending your pictures and providing your rhinoplasty history. If I understand your goals now, you would like some bridge augmentation and the nasal tip brought back down. (derotated) Both of these can be achieved by onlay cartilage grafting of the bridge and the infralobular tip area. Assuming your septum was not harvested during your initial rhinoplasty you have adequate graft material to accomplish both nose reshaping goals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Six weeks ago I had my right (undescended) testicle removed due to a mass detected by ultrasound and replaced with a Mentor Coloplast prosthetic testicle implant. This implant is very ill-fitting, riding high and fixed in position by a permanent suture. Two weeks ago I asked the urologist to remove the permanent suture because it was painful and did not permit any movement of the implant. Unfortunately, he accidentally punctured the implant which caused it to leak and deflate. He then stitched up the incision he had made trying to cut the permanent suture (which is still there causing pain/irritation) and said that another surgery would have to be scheduled. He is willing to replace the Coloplast prosthesis with a soft/solid version like you use, but the surgery center here will not permit the surgery because this type of prosthesis is not FDA approved. Can you help me?
A: Your experience with a saline-filled testicle implant has exhibited all of its downsides. A saline implant usually feels very hard (water under pressure), has a lifelong risk of eventual rupture and deflation and the frequent use of a fixation suture can prohibit natural mobility. A silicone testicle implant that is to sutured in has none of these liabilities. They always feel much more natural. Getting a good size match is always important and a silicone prosthesis has much bigger size options than those that exist in saline-filled implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a reduction genioplasty (chin reduction) six days ago and there is some significant swelling. The doctor who performed the procedure said that I have to wear a compression garment around the chin to help the tissues to mold around the new chin. Whenever I remove it I find that the tissue has taken the shape of the garment. Will this be the long term result once the swelling goes down? Does the garment play any role in the shape?
A: It is important to realize that the result from any bony genioplasty procedure, including a chin reduction, takes a full six to eight weeks to be fully seen. At just one week from surgery there is tremendous swelling, most of which has not yet resolved yet and causes a lot of chin distortion. Thus your chin will appear mishapen and far from the final result regardless of whether you wear a compressive garment or not. The chin strap will help some of the swelling to go down quicker and get a normal chin shape sooner than if it was never worn at all. But I would certainly not worry about the shape the chin is caused by the garment with the early swelling present.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I had a large chin implant put in about four years ago. I have finally become convinced that it is too big and I want it removed.
A: When it comes to chin implant removal, I have some pertinent questions about your existing chin implant:
1) What incisional approach was used for placement? (intraoral vs submental)
2) What type of chin implant is it? (Medpor vs silicone)
3) What size is the chin implant (amount of horizontal projection)
4) In managing the chin ptosis that will likely occur with chin impant removal alone, what management strategies were you thinking? (intraoral resuspension, submental tuck up, replacement with sliding genioplasty)
Removal of small chin implants, or those more recently placed, is as simple as just removing the implant. But with larger chin implants, particularly those that have been in for some period of time, it is not so simple. While removal of the implant is simple, what happens to the overlying chin pad must be considered. It has been stretched out and will slide off the chin bone once the support has been removes creating a chin ptosis condition. How this should be managed must be consider as part of the chin implant removal surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking jawline enhancement. What really bothers me is the lack of definition in my jawline and the bulge under my chin. I feel like everything just blends together, I also have no cheek contour.
I had liposuction done twice in the under chin area (never along the jawline though). I had a chin implant and then another chin implant stacked on top of the first one by a different doctor two years later. (so I have 2 chin implants on top each other)That same doctor also did buccal fat removal in the same year.
As you can see from the pics there hasn’t been much progress, I would love to have a stronger/sharper more defined jawline. What do you recommend? I am 30, 5’3 and normal weight range for my height 125 pounds.
A: Thank you for sending your pictures. I can clearly see all of your stated facial concerns. Given that you have a double stacked chin implant and a persistent submental bulge, you need to remove your chin implants and have a replacement sliding genioplasty. Pulling the chin bone forward will stretch out the neck muscles which is clearly the source of the bulge. It will also create a greater horizontal chin projection and will make the chin look more defined and less round. With the sliding genioplasty vertical lengthening jaw angle implants can be done at the back of the jaw to give it more shape and angularity.(total jawline enhancement) For the cheeks you need a small malar shell implants to give them more projection. The triangulation effect of chin, cheek and jaw angle augmentation will have the biggest effect on changing the shape of your face to make it more defined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting buttock implants. I am small but want a nice round buttock size result. I have attached what my buttocks looks like now and the kind of result I want. I think I need 550cc buttock implants. What is your recommendation on implant size?
A: In looking at your pictures, you have very small buttocks and a petite body frame. You are simply too small to have such large buttock implants, at least in an intramuscular location. You are either going to have to accept a much smaller buttock augmentation result than you desire (with lower risks) or have larger implant sizes that carry much higher short and long-term risks. It is important to have realistic expectations based on what your tissues can tolerate. This does involve the placement of implants whose initial acceptance and long-term success are based on a delicate balance between tissue stress and the volume of the implanted material.
There are my three buttock implant size recommendations based on how much risk you want to take:
Safest 270cc intramuscular 350-375cc subfascial
Aggressive 330cc intramuscular 425cc subfascial
Riskiest not possible intramuscular 500cc subfascial
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reduction surgery. My chin sticks way out and doesn’t fit the rest of my face. How would I go about fixing this? I have attached pictures for your review.
A: Thank you for sending your pictures as they clearly show your lower facial concerns. Pure horizontal chin excess is one of the most challenging of all chin reshaping surgeries in terms of deciding the approach. A submental skin incision approach allows for the most effective technique as both the excess bone and soft tissue can be removed….albeit at the aesthetic ‘price’ of a submental scar.The intraoral wedge reduction and reverse sliding genioplasty method is scarless but has the potential to create some submental fullness as the chin is moved back. (as it does not address the soft tissue excess) The bone is cut and then slide backwards. (hence the term reverse sliding genioplasty) Because the chin bone is moved backwards it pushes the attached soft tissue with it, creating a potential submental bulge.
The choice between a submental or intraoral approach to chin reduction surgery depends on which of their tradeoffs you can best accept. (submental scar vs submental fullness) Most men would choose the submental scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin augmentation. I’ve gotten other reviews for doctors and most of them said for me to try chin fillers or a sliding genioplasty.
A: There are three chin augmentation methods which have their own unique advantages and disadvantages. It is not a question of whether one method is better than the other, it is as question of which one is most appealing to your aesthetic needs. An injectable chin augmentation method uses synthetic fillers which has the advantage of being non-surgical but the disadvantage that it is temporary as the filler will dissipate over time. This method only makes sense if one is uncertain as to whether chin augmentation would be beneficial so it is a good trial method. A chin implant offers a permanent augmentation method though a fairly straightforward operation whose result depends on the implant style and size chosen. Its disadvantage is that it is an implant that creates the effect and, like all implants, has some surgical risks. (infection, asymmetry, under/over correction). A siding genioplasty moves the actual chin bone and is the most ‘natural’ chin augmentation method. It is the most invasive surgery and requires the longest recovery from a swelling standpoint but it has the advantages of being a natural method that will not cause any long-term potential issues once the bone has healed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had orbital tear trough implants, Alloderm to eyelids, canthoplasty, and a mid face lift performed on me almost three weeks ago and I am not happy with the results. I wonder if I should have the implants removed and Alloderm removed (or possibly injected with steroid if possible)
My cheekbones seem to high and a little fake. I previously had 1ml of JuvadermVoluma in them prior to surgery. Is there any chance to dissolve them? Would it make a difference? I look forward to hearing back!
My plastic surgeon suggested two options:
1. I either have the tear trough implants removed as soon as possible, or
2. Wait 3 months to re-evaluate
Thank you so much.
A: You are going through what many young men experience after this type of facial surgery….impatience and jumping to premature conclusions. You are just three weeks from surgery and it is important to understand that the true final result takes a full three months to see when all the swelling has subsided, the tissue have shrunken around the implants and you have become accommodated to your new look. You are making a change to your face that you have seen your whole life. There is going to be a transitional phase where it will be uncomfortable…all change involves this process.
Your options are to either wait out the three months and be certain of the result or prematurely reverse some of the surgical changes. It is important to realize that you had this surgery for a reason and you probably put a lot of thought into it. It would be a shame to just throw some or all of the surgical efforts away before you even saw what the final results were.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to improve my face and have attached pictures which show my concerns. For some reason, the selfies make my face look longer than it really is. I have a very square face. I would like very much to have more of a heart shaped face… and to address the skin laxity that is showing my age. These pics are without makeup and do show a little of the perioral mound that keeps a heart shape away. I am wondering if that needs to be removed or if I would do better with a form of facelift to lift some of the fullness/wrinkles from my mouth area. By the way… I have had an upper bleph (love it!), but do wonder about a little brow lift as well. I have a very short forehead and low brows. It looks quite wrinkly when I try to keep them raised. Thank you.
A: Thank you for sending all of your pictures. Selfies do create facial distortions as your face is certainly not long but vertically short with its more square shape. Your pseudo perioral mounds are really caused by the skin laxity along the jawline. As the skin falls forward it ‘piles up’ against the corner of the mouth creating these tissue mounds. Ideally what you need is a small ‘tuck up’ lower facelift also known as a jowl lift. That will resolve the jowls and eliminate the buildup of tissue in the perioral mound area. To help make you face less square and more heart-shaped some vertical chin lengthening would go a long way in that regard. This can be most simply done by a small vertical lengthening chin implant but also by am opening bony genioplasty as well.
For the brows an endoscopic browlift would be beneficial as it would not only lift the eyebrows but would vertically lengthen the forehead as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if it’s possible to get a cheek augmentation at the same time as a rhinoplasty or would swelling from either interfere with the other. I also have a deviated septum. Do/can you fix that as part of a more general cosmetic rhinoplasty? Thanks.
A: Having a rhinoplasty and cheek augmentation at the same time is both common and not problematic. Even though they are anatomically close the tissue disruption of one does not affect the other. The swelling from these procedures does not start until after surgery so one procedure does affect obscure the visualization of the other.
In a rhinoplasty it it very common to perform and achieve dual benefits, changing the shape of the nose as well as improving one’s breathing. Known as a septorhinoplasty, it is both an internal and external nasal procedure. Besides being able to straighten a deviated septum, the cartilage from the septum can also serve as a support material for the cosmetic nose reshaping part of the operation. A septorhinoplasty is truly a synergistic procedure that for some patients absolutely has to be done together. In some cases the functional airway part of the operation may be covered by one’s health insurance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to enquire about lower blepharoplasty. I am a 45 year old male and have been suffering from eye bags getting worse over the last five years or so. (particularly the last year) I have been to see three plastic surgeons about this, but am confused as to the approach to take. All three plastic surgeons have confirmed it is herniating fat and not a tear trough or other problem that is causing the bags.
The first surgeon preferred a transcutaneous approach, though said I may benefit from a tiny skin excision, it may not be needed. The other two both said skin removal was not needed and both recommended the transconjunctival approach with no fat transfer or redraping. Now, since I have done quite a bit of research on this I realize that a transconjunctival approach is regarded to be less risky, due to not cutting through the lower eyelid muscle, especially since a skin excision is not required it seems a needless risk.
However, where the last two surgeons differ is that one said they rather be repairing the lower orbital septum, (he called it Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty) and that this would involve a miniscule fat removal as the septum would hold the fat pads in a more natural position. He said this would not only give better long term results in terms of preserving eye shape and lid level, but also prevent a common problem of a skeletal look that can arise from a basic transconjunctival approach, he even claimed that this marginally would improve the upper eye skin look, as the eye would be sitting more naturally in its socket – looking at before and after pictures I can see this is indeed a happy side effect.
What I would like to ask is:
1) Which approach would you take (I am happy to send in more photos)
2) Is it common with a basic transconjunctival approach to have a skeletal look long term or is this always simply caused by excess fat removal?
3) Would a transconjunctival approach, with septal suture repair produce more inherent risks or recovery time, and if so would the results be that much better that (2) such that the risk is worth it?
A: In looking at your pictures and your age, it is clear that you don’t need skin removal. Thus a transconjuncival approach to your lower blepharoplasty should be done rather than a transcutaneous one. Your debate is in how to handle the herniated fat pads…either subtotal removal or retrograde repositioning. (septal reset) The simple answer to this debate is if you can keep your fat and it can be brought back in (like a hernia repair) this is always better long term. However it is much more technically challenging than fat removal through the transconjunctival approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get augmentation of the brow ridge/supraorbital rim. I also have a backward sloped forehead which I was hoping to make more vertical at the same time. I have consulted with another surgeon who told me that my lack of supraorbital rim projection extends to the lateral orbital rim too. So I was wondering whether it would be possible to design a custom implant to cover all three of those areas at once? A couple of other issues are these;
– It appears as if my supraorbital rim is not only under projected but also that it sits at an upward angle ‘away’ from my eyeball itself. Is it possible to fashion an implant that both angles downwards and sits lower down on the supraorbital rim to ‘surround’ the eye?
– The same issue seems to be apparent with the lateral orbital rim in that it sits too far away from the eyeball. Can the same be done here as with my question above?
– Not only is my forehead backward sloping and sagitally underprojected, but it is also horizontally convex. The sides of my forehead sit too far back relative to the centre of the forehead. Is this a fixable issue?
A: Using a custom forehead and brow bone implant concept, it can be designed to any desired shape and dimensions. The key issue is not whether an implant can be designed to accommodate your aesthetic desires, but whether your tissues can adequately stretch to accomodate the desired augmentation. This is of a particular issue as one tries to create augmentation on the lower aspect of the brow bone. Besides there being the supraorbital nerves (responsible for feeling sensation of the forehead) which exits through the brow bone and can become injured when an augmentation drops below the brow bone, this is also a brow bone area that is hard to expand as the tissues are very tight.
The other aesthetic issue is that it is potentially problematic when the forehead augmentation crosses the temporal lines at the side of the forehead. Unlike the bony forehead, the sides of the forehead (or the upper temporal region) is muscular and not bone. Any augmentation that crosses into this area can create an unnatural line of demarcation. (the temporal line is a natural line of demarcation)
In short, a custom forehead and brow bone implant can be designed to meet most of your aesthetic augmentations. But there are some aesthetic considerations that may not allow every aesthetic/forehead desire to be met.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about three years ago I had a Mentor Coloplast prosthetic testicular implant put in. It is sooo hard and unnatural feeling. The good news is It isn’t sutured in and I do like having the mobility. I really want to know if they make a softer squisher testicle. I know a prosthetic testicle will never be 100% like the real thing, but this is sometimes causing me pain because it is so rock hard.
A: Saline-filled testicle implants (Mentor Coloplast) are by their very composition hard and quite unlike what a natural testicle feels like. Saline placed inside a silastic silicone shell creates a very firm prosthesis. It is fundamentally a flawed concept for a testicle implant not to mention the risk of deflation and need for eventual replacement. Very soft low durometer silicone testicle implants exist that feel very similar to a natural testicle. They are extremely soft and squishy and have no risk of eventual failure or need for replacement. This is because it is a solid implant material and not a fluid-filled bag.
With an existing testicle implant in place, it would be a straightforward surgery to remove the hard saline implant and replace it with a very soft silicone testicle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m inquiring about a cheekbone augmentation and possibly a bossing reduction. I’ve always been bothered by my side profile. To me, it looks more flat (or even mildly concave) than convex. I was seen by a craniofacial specialist about this concern, and he stated that my forehead shape and slope were fine, but I had very flat cheekbones and that it could be fixed. I’m not certain why I didn’t speak about a cheek augmentation procedure at the time.
I was wondering if a cheek augmentation, possibly a frontal bossing reduction, would help give the impression or a more convex profile. I’ve attached images. It may be hard to see in the images, but the areas under my eyes are completely flat, and vertical.
A: Thank you for your inquiry and sending your pictures. I would say that you are correct about your facial profile in regard to the lack of midface (cheek) projection and some frontal bossing protrusion. On a practical basis for a man, it is easier to undergo cheek augmentation than upper forehead reduction because of the incisional access and the resultant scar line.
Your cheek deficiency is really a more infraorbital-malar deficiency that encompasses from under the eye out to the sides of the cheeks. This is why you have a negative vector. (the cornea of the eye sticks out further horizontally than the projection of the cheeks.
This is not ideally treated by a standard cheek implant as this will provide no improvement to the under the eye area. This is best treated by a custom infraorbital-malar implant style.
Dr. Barry Eppley
Indianapolis, Indiana
