Your Questions

Q: Dr. Eppley, I had subfascial buttock implants placed three week ago. My doctor wanted to keep the skin stitches in for a long time so that it would heal without coming apart.  I’ve been keeping an eye on my stitches now that I able able to see them better. I am seeing an opening develop that I did not see until now. This opening in the incision worries me. Should I get it restitched to assure that it closes properly when I go in for my one month checkup?

A:  What you are observing after your buttock implants is very common and, quite frankly, expected. This is why I keep the the intergluteal incisional sutures in for so long. Every intergluteal incision will develop small openings such as you have and they never occur until 2 to 4 weeks after surgery. I do not close them because the sutures will never hold. They need to be allowed to heal in on their own. There are 3 other layers of tissue suturing under that of the skin closure so such small openings are not a concern. I would recommend topical Silvadene dressings which will help the small open area granulate in faster and is a potent antibacterial as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual question. I know you are an expert at the corner of the mouth lift. My lips turn up at the sides too much as it is. Is there  any way you could perform a subtle corner of the mouth ‘drop’…a reverse corner of the mouth lift if you will. This would be a reverse procedure. When I pull my lips down slightly they look as good as possible and being a professional entertainer I could really use this improvement. Also can the lower lip be lengthened slightly– thank u so much for your time!

A: I have to admit that I have never done a ‘reverse’ corner of the mouth lift nor has anyone ever requested it before. But like a traditional corner of the mouth lift, the reverse can be done I am sure. Some lengthening of the lower lip could be done at the same time. Unlike the corner of the lift which is done on the upper lip, a corner of the mouth ‘drop’ would be done on the lower lip.

I would need to see pictures of your mouth to give a more qualified opinion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation. I’m 25 years old and I have problems with my facial aesthetics. My forehead is more protruding than my midface and my lower third. This is easily observeable in sunny places, my forehead is highlighted but the rest of the face (except the nose) in shadow. Since my bite is good and my jaw quite strong, I would think a chin implant is a good idea, but is there an really effective method to bring the midface forward without a LeFort osteotomy?

A: As for the chin implant I would need to see pictures to make a helpful comment on its benefits for you. There is a very effective method to bring the level of the face around the nose forward which would create the equivalent of LeFort I osteotomy effect. Combined paranasal/premaxillary- maxillary implants can have a very powerful midface augmentation effect. Cheek implants are also useful but they create a zygomatic augmentation (upper midface) not a maxillary (lower midface) augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about temporal augmentation. I just got cheek implants and am modestly happy with them. I wanted to know if temple implants can co-exist with cheek implant. My surgeon has explained to me that temple implants are not safe due to a sensitive nerve in that area, and something he does not practice, nor advises. 

A: I am afraid to say that what your surgeon is telling is inaccurate and anatomically incorrect about temporal augmentation. Temporal implants are placed in a subfascial pocket through a small incision in the temporal hairline. There are no nerves in the subfascial temporal plane which is directly on top of the temporalis muscle. Your surgeon is likely referring to the subcutaneous temporal location where the frontal branch of the facial nerve runs. The subfascial is below that location and is perfectly safe.

Cheek and temporal implants can co-exist because they are in completely different tissue pockets even though they are right next to each other. Cheek implants can make the temporal region above it look hollow/deficient and it is not rare in my experience that the cheek implant patient subsequently goes on to have temporal implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had facial fat grafting six months ago with 30 cc of on each side of the face into the bottom of the cheeks, smiles lines, nasolobial folds and near the mouth! This has unfortunately lead to a very bad new look! Fat lumps develop in the above mentioned areas as fat was injected too superficially. I read a recommendation from Dr Eppley on RealSelf that fat can be surgically excised! Would like to know more about this procedure! is it done from outside the cheeks or from inside the mouth?

A: There are numerous methods to try and reduce excessive fat contours after facial fat grafting. Surgical excision is rarely used unless the fat is located in an area that is easily accessible through a facelift or blepharoplasty incisions. Small cannula or microliposuction is the most effective method near the central face and mouth areas. This is usually done through a small incision inside the corners of the mouth.

Other non-surgical options to get rid of fat grafting lumps include steroid injections (low dose Kenalog) and the use of deoxycholic acid solutions. (originally known as Lipodissolve injections and now under clinical trial investigation as ATX101 by Kythera)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a breast asymmetry problem. I am 26 years old and the mother of one. During the period of breastfeeding, my child developed a likeness to my left breast which cause it to fill faster with milk and now my breast has stretched to such an extent that my right breast is almost half the size of my left breast, I live in Guyana, but the expertise is not here in this area (plastic surgery) I would like to know which one of the surgeries for the breast would be right for me and also do you deal with clients who may come from another country for plastic surgery.

A: There are multiple approaches to treating breast asymmetries and the choice of procedures depends on the size and shape of each breast and their differences. The first and most important question is…is one of the breasts the size and shape that is desired? In your case that would mean is the right breast the goal to try and make the left one look like again? If so, then a breast lift and/or reduction on the larger left breast may be all that is needed. If neither breasts are ideal or even the  ‘better’ one needs improved, then bilateral breast reshaping procedures would be needed.

A unilateral breast lift is a relatively straightforward procedure that could be done as an outpatient under general anesthesia in about an hour of surgery. I will have my assistant Camille, who handles all of my far away patients, contact you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 70 years old and got saline breast implants forty years ago. Recently my left saline implant ruptured. Need surgeon with your skills. I am  confused about options with my saline breast implant deflation. I saw you on Real Self. Can you help me please? Thank you. 

A: Having saline breast implants that have lasted for forty years is way beyond what one would expect them to last without suffering a deflation. The duration most saline implants are typically expected to last is in the ten to twenty-five year range. I have never heard of a saline breast implant lasting four decades!

With a recent saline breast implant deflation, the simplest and most economically efficient option would be to simply replace the ruptured implant with a new saline implant. Breast implants replacements are easy because there is an established implant pocket already. You could, of course, switch to silicone implants in both breasts if you still want implants and want to eliminate any future risks of an implant deflation. (since silicone implants do to deflate)  As an alternative option, you can simply remove both implants if you no longer desire to have them and wish to most assuredly eliminate any future breast implant concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a custom brow bone implant. My problem is that my brow bones are very low, typical Asian. My eyelids are protruding.I believe this makes me look too soft, messy in the eye area, sad etc. not manly. I have thought of this for at least five years. My  brow bone is less protruding or equal to eyelid protrusion.

For men the brow bone should be substantially more protruding than the eyelids, almost close to protrusion of upper lip.

What I wish for is a permanent brow bone implant. I want an attractive manly forehead and supraorbital rim area. I want the brow bone to protrude more than eyelids and close to protrusion of upper lip based on analysis of male faces I want to look like.

A: What you are seeking is a custom brow bone implant. Most likely this would have to be a combined forehead brow bone implant to create the best overall effect. This type of custom made implant is made off of the patient’s 3D CT scan. Its final shape requires some artistic design but how much brow bone augmentation is needed can be determined by looking at the difference in the brow-eyelid position in the profile view. Thus type of facial implant would need to be placed through a scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in double chin correction. Attached you will find some pictures that I took–today during my lunch break! Looking at me straight on, at a flattering angle, you can tell I have a round face but the double chin isn’t noticeable. When I smile widely, laugh, or am viewed from my profile, it is clearly evident. What are my treatment options? Will liposuction alone work as another doctor told me? Let me know your thoughts!

A: Thank you for sending your pictures. While there is certainly some subcutaneous fat to liposuction, that will give you a modest improvement only. Necks like yours almost always have a subplatysmal collection of fat in the midline that will not be changed by liposuction. This requires a submentoplasty technique to maximally tighten the neck angle. You also have a bit of a horizontally short rounder chin. This adds a third factor to the double chin appearance. Adding a small central button style chin implant will add a little more horizontal projection and change the frontal chin shape to more of a tapered chin look.

In conclusion, it is all about the degree of double chin correction you are seeking.Liposuction alone will produce a modest improvement, a submentoplasty (which includes neck liposuction) will make a good change and the final addition of a chin implant will make the best overall double chin correction. As you can see neck liposuction is the most basic approach but does not produce the best double chin correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Twenty years ago, I had a facelift done. Until six months ago, all was well. However, for some time, I have noticed that along my hairline, little “slits: appeared followed by something quite hard. Recently, my face has begun to drop dramatically to the point I’m embarrassed to be in public. The comparative pictures are unbelievable. I have Medicare and Tricare for Life. Is there any possibility insurance would cover the repair or for a new facelift? I’m desperate at this point. 

A: Twenty years is a tremendous amount of time to get the benefits of a facelift. Most facelifts have largely degraded and the benefits lost by ten to twelve years after the procedure. I have no idea what the issue is with the ‘slits’ /hard knots in the hairline. Although most plastic surgeons use dissolvable sutures for their facelifts, your surgeon may have placed permanent sutures deep and they may be working their way to the surface after so many years. That would be the only explanation I could fathom for their presentation. No medical insurance is going to pay for facelift surgery. This is a purely cosmetic procedure that is paid for upfront undoubtably just like it was twenty years ago.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed about six months ago by another surgeon. It is not adequate at all and now what the surgeon promised the result would be. Besides its size my other concern is the location of the exterior scar on my face?  It seems to be very close to the front of my chin, in fact on some  ‘shrugging’ type expressions it seems to roll over to the front.  Would this be in a better location upon my custom jawline implant revision? 

A: One of the things you learn in placing custom jawline implants or even vertical lengthening chin implants is the typical location for the submental incision will be too far forward if not changed from its traditional submental skin crease location. When the chin is lengthened vertically and comes forward, the typical location of the submental incision is too far forward and will almost end up on the chin point as opposed to being tucked on the underside of the chin. Therefore, the incision  needs to be placed further back than most surgeon’s think as the implant rolls it forward. That incision location can not really be changed now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I should start by saying thanks for the temporal implants two months ago. They really seemed to do the trick, at first. For the first ten days or so I was thrilled with the results, but I didn’t realize how much of the fullness was due to swelling. Now it has been nearly 2 months and I can assume the shape is final. 

I’ve attached a picture (series of 4 pics) that illustrates the situation. The second image is 48 hours after surgery, you can see the ideal fullness is there, especially on my right temple (and from what I can feel, the implant on the right feels/looks thicker than the one on the left). The last 2 pictures on the right are from two months later. As you can see, the swelling has faded and the implants don’t quite fill out the space entirely. They do a nice job filling out the hollowing near the bottom, but they fade out up higher and the classic temple defining shadows/lines returned. 

I do realize the results are significantly better than the “before”, that I am grateful for, but I’m wondering if you have bigger implants available than what you gave me. They would also have to maintain thickness as they travel up towards the hairline. Something that would give me a final result that matches the 48 hour picture. Maybe that means making them convex, I don’t know. Is it even possible to replace them? I am just trying to figure out what my options are, if any. Thanks

A: Thank you for the follow-up. The reason the temporal implants don’t reach what I can Zone 2 of the anterior temporal region is that they can’t. They are not made to go up that high. They have a superior height of 4 cms, which means their greatest reach vertically will be 4 cms above the zygomatic arch with the last centimeter being tapered to avoid an obvious step off. (so they really only augment significantly 3 cms above the arch) There are no temporal implants that will extend all the way up to the anterior temporal line. Custom ones can be made to do that if desired but such large (vertically high) temporal implants are not standard or stock styles that are commercially available. It is relatively easy to replace your existing temporal implants with larger ones. It is not a surgical issue, just a design issue to overcome.

Your issue is not rare in temporal augmentation which is why I am currently working on extended temporal implant designs that can reach all the way up to the anterior temporal line by the forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a facelift to get rid of my neck sagging and jowls. Is there anything else you see in my pictures that you think would be helpful to create a more refreshed and younger facial look? 

A: Thank you for your inquiry and sending your pictures. You would do really well with a lower facelift which will redefine your jawline and reshape the neck. You do have a bit of chin ptosis (roll of tissue on the underside of the chin and a small chin implant would be helpful to eliminate that and add to improvement in the entire jawline appearance. You do have a little extra skin on both eyelids (and just a bit of puffiness of the lower eyelid as well due to fat herniation so doing blepharoplasties at the same time (which is very common) would add to the overall facial rejuvenative effect. Your thinner skin and tissues also makes for a good outcome as these tissues show the effects of facial skin redraping the best as opposed to thicker heavier tissues. It is more common to do additional procedures with a facelift than to do a facelift alone.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am hoping to set up a consultation with you to discuss the possibility of undergoing chin/neck liposuction for double chin. This is something I am quite self conscious about and have considered off and on for years. I am not overweight, but regardless of my weight over the years, I have always had it. I am actually a nurse at one of the local hospitals where you work and have cared for many, many of your patients! Although I haven’t had the pleasure of meeting you in person, I have worked very closely with your team of residents, fellows, and fellow staff physicians. I spoke at length yesterday regarding the matter with one of the local plastic surgeons. He explained to me the risks and benefits, length of time I would be out of commission, and what to expect with results. He is on board if I am. But with all procedures, especially cosmetic ones, I know that it is important to get multiple opinions. I am just curious to hear what you think as well.

Please let me know at your earliest convenience!

A: When it comes to double chin correction the question is not whether you can undergo liposuction of the submental and neck region, it is just how effective it would be in achieving the goal of reducing/eliminating the double chin. There are numerous components that make up a double chin which include the fat layers (subcutaneous and/or subplatysmal), amount of bony chin/jawline projection and the tightness or laxity of the platysmal and hyoid musculature. Knowing what anatomic elements comprise the problem will allow one to choose the best treatment. If all of the double chin problem is subcutaneous fat, then simple liposuction will suffice. But if there are other elements that contribute to the double chin then the result from liposuction may be less than completely satisfactory.

Without seeing pictures of you, I can not say how any of these anatomic/diagnostic considerations may apply.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting head width reduction surgery, cheekbone reduction surgery as well as surgery to augment the back of my head. The first photo I attached is in regard to head width reduction and cheekbone reduction surgery. From the info on your website, I see you do removal of the muscle after the yellow line in my photo.  I am curious to know if you can do removal of muscle after the red line in my photo. Also, I will always have very short hair on the side, since it make my head looks smaller. How visible will the scar be after the width reduction with my short hair? 

I had a cheekbone reduction before but my surgeon didn’t reduce any more cheekbone after the first blue line in my photo due to concern of nerve damage. Since most of the width of my face is in between the two blue lines. The cheekbone reduction i had is largely ineffective in making my face more symmetrical and narrower. I was wondering if you are able to reduce the cheekbone between the two blue lines where my previous surgeon was concerned with nerve damage 

Lastly is in regard to the augmentation of back of my head, my current head shape is similar to the baby in the second pictures. I am curious in getting a custom implant to make my head look more normal.I consulted with a craniofacial he advised me against a custom implant because of high risk of infection. How high is the infection rate of these implants, and How much will total cost of this specific surgery be including getting a 3d CT scan, a custom implant made, and all the other fees including surgeon fee? 

A: When it comes to temporal muscle reduction, the actual line of reduction is from the top of the ear angling upwards to just behind the temporal hairline along the forehead, so it is in front of the red line that you have drawn. Most of the incision is behind the ear and it is done largely endoscopically above it.

The cheek bone a you are illustrating is the tail end of the zygomatic arch where it attaches to the temporal bone. If this part of the cheek bone is not fractured inward with the front part, little change in cheek bone width will result. An osteotomy is done in that area through a small incision at the junction of the beard skin and non-hairing skin. The temporal branch of the facial nerve runs in front of this incision so there is no risk of nerve injury. This is actually a standard approach to cheek bone reduction osteotomies as both the front and back ends needs to be cut and moved inward.

I have done many custom occipital skull implants as well as many other implants for other skull augmentation areas. I have yet to see an infection so the claim that they are prone to a high rate of infection has not been my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. I have a very boxy figure and I am a model. I am looking to get more of an hour glass figure and gain more confidence in my appearance. As of now I refuse to take photos straight on because they make me look wide, but I strongly believe having those ribs removed will assist me in achieving those goals. Right now my measurements are 34C bust and then my hips are 38″ at the smallest point of my midsection I am 26″, and when my personal trainer measures me at my “real waist” it is 33″ I am 5’9 and 133lbs. I would really like to have a better figure, but with wide hips and my ribs I feel like it is difficult without the surgery. What is your professional opinion? 

A: I think you who feel and know your own body better than anyone has the best perspective on what may be of benefit to an improved body shape. the question is not whether rib removal will be effective but exactly what ribs are best to remove. I would doubt that 11 and 12 are the ones as they lie too posterior and do not really wrap round the torso. Thus their removal would have no benefit to bring in the sides of the torso. More likely it is ribs 8,9 or 10. If you could send me a picture of the ribs marked on your ribcage (with a Sharpie) where you feel the greatest reduction is needed, that would be very helpful in determining the exact rib numbers to be removed for your rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a medium sized Implantech Terino Extended Anatomical implant placed about a year ago. I am interested in getting jaw angle implants and was wondering what style you think would best meet my needs. I like the flared out look of the Implantech Lateral Mandibular Angle implants, however, it also appears that I could use some vertical drop down given by the Posterior Mandibular Angle implants. It looks like the off-the-self posterior implants offered by implantech give 0.36mm of added width. Would this posterior implant give me the flared out look from the frontal view while dropping by jaw angle at the same time?

A; I do not find that any of these types of jaw angle implants would provide a ‘flared out’ look. They can add fullness to the jaw angles but they are not the style of jaw angle implant that can provide an angular flare, particularly if the implant provides any vertical lengthening. A different style of jaw angle implant is needed for that jawline look which is not currently commerically available for off-the-shelf catalog availability.

Dr. Barry Eppley

Indianapolis, indiana

Q: Dr. Eppley, I was writing interested in learning more about facial asymmetry surgery. I noticed that one side of my face is a bit fuller than the other. It manifests in the forehead and the jawline. I am wondering if it is advisable to do anything about these types of asymmetries or is it best to just ignore them. I have attached some photos to provide some examples of what I am referring to.

A: The answer to your question about facial asymmetry surgery and whether it is worth it depends on the degree that it bothers you, what would it take to make a correction and what are the risks in doing so. In terms of improving any facial asymmetry it is infinitely easier to add fullness than it is to reduce it. This is particularly true in the forehead due to surgical access. (incision needed to do it) It is less true in the jawline since the incisional access is intraoral. I would need to see better pictures of your face (non-smiling straight on picture) to do a computer imaging analysis to see if you feel such changes would be aesthetically beneficial and what type of facial changes those would be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a chin reduction for the vertical height of my chin as well as making the projection smaller when you look at my profile. I also have a chin dimple right in the center of my chin that I want removed and smoothed out. I am a 23 year old female. What can be done for me to achieve this? Also, I worry about loose skin after the reduction, what can be done to avoid that? I have a very tight jawline and I do not want to lose the definition.

A: Chin reduction can only be done only one of two ways from an incisional standpoint. Either it is done from an intraoral (inside the mouth) or a submental (under the chin) approach. Which is best depends on the dimensions of the bony reduction and how much, if any, excess chin pad tissues may result. I only see a frontal view picture attached and I need a side view picture (non-smiling) to determine what the horizontal reduction needs are if any. Most effective chin reductions are done from a submental approach to address this soft tissue concern.

The chin dimple is best treated simultaneously with fat injections to try and reduce/eliminate it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could give me your opinion on the use of Aquamid. I’ve noticed in the US it isn’t FDA approved and have read about complications on the use of this injection product. My surgeon wants to use this around my jaw as my custom jaw implants have produced some dents and hollows around the point of the jaw to “fill them out”.  However as a patient I am very skeptical on this although it sounds rather straight forward.

A:  Aquamid, like all injectable filler materials is straightforward to place. It is just a question of whether the potential problems they can create are equally straightforward to solve.

All so called permanent fillers that create their effects by the placement of non-resorbable particles are prone to their own unique set of problems such as lumps and eventual tissue reactions. While it may never happen, and probably statistically won’t, when it does it will be a challenging problem as the material can not be removed from the tissues. There are many reasons Aquamid is not approved in the U.S. but, even if it was, I would likely never use it. There are numerous other options out there to use to help augment custom jaw implants that don’t have these potential problems or have a better proven track record. (e.g., fat injections, small mesh implants, Radiesse and Bellacol injections)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 68 years old. Several years ago I was diagnosed with Graves Disease and am currently in remission (forever I hope). However, due to the disease, medication, age and possibly genetic, my hair has become very fine and thinning all over. This in turn has accented my VERY flat back of the head and top. I cannot wear a headband because there is no where to hold it. The band slips off. My face looks much larger due to no balance of the skull. I will probably have to wear my hair short because it will not hold any style. So I am looking into reshaping. I am becoming more of a recluse due to this as I feel so unattractive. If you could tell me what augmentation approach would work for me.  (similar to the female full back of the head that you show in your example) What also would be the most cost effective method to do it? I would certainly appreciate it. Thank you for your time.

A: Skull augmentation of the back and top of your head can be done with an implant. While a custom approach would be best using a 3D CT scan, that does add to the cost of the procedure. The most cost effective method would be with the use of preformed skull implants. Having done many custom skull implants over the years, I have a variety of preformed implants available that are close enough in shape that they would work for many other patients. By cutting peripheral slits in the preformed implants, like a fan, they can be made to lay flat and flush on just about any curved skull shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin ptosis correction.  I had two prior jaw surgeries (one orthognathic with sliding genioplasty). My mentalis muscle has been weakened and my lower third (chin particularly) looks bulkier because of this. There is some excess soft tissue around my chin as well (skin, maybe some fat). I’ve been thinking about mentalis muscle re-suspension, when I stumbled across this article which explains an alternative of Vertical Wedge Excision of Chin Ptosis.
This seems to me like a minimally invasive procedure with dramatic results that comprehensively addresses all laxity (muscle and skin). I wanted to ask you for your opinion on this, since I am worried about the longevity of the result when no sutures are used to resuspend the mentalis muscle. Perhaps a combination of both would be the way to go? Would you be able to perform this procedure preferably under sedation rather than general anesthesia as it involves no bone work? Also, since I am not from the States and would like to travel only once, would you be able to give me an indication of the approximate cost? I have attached here a picture for your reference – my problem seems to be largely excess soft tissue around the chin which makes it longer, bulkier horizontally and vertically and even asymmetrical, similarly to the pictures shown in the article that I linked above.

Thank you for your advice in advance.

A: Chin ptosis is a multifactoral problem that has different anatomic variants. Thus there is no one single best chin ptosis correction procedure. The first important classification is whether the chin ptosis is associated with a lower lip sag or not. If there is no lower lip sag there is no benefit to mentalis muscle resuspension or trying to move the chin tissues back upon the bone.

The next important chin ptosis classification is whether there is excessive chin tissues or whether there is a normal amount of tissue volume. If the overhanging chin tissues are normal in volume, and their resection may be associated with causing a lower lip sag, then resuspension should be done. When the ptosis is caused by excessive chin tissues then resection would be the appropriate approach.

When it comes to resection of the chin pad, it can be done horizontally (under the chin), vertically (as shown in the article) or through a combined vertical and horizontal technique. (inverted T) There is no question that adding a vertical direction to the chin pad excision provides an additional element of chin pad reduction that is helpful, it is just a question of the scar that can result from it. Once you go vertical, the scar is going to be noticeable since it is above the submental region. Whether the scar would be aacceptable depends on the magnitude of the excessive chin pad and the patient’s skin type. This article, which does not really describe a novel technique in my experience, shows a single case done on a Caucasian female. The resultant scar can be quite different in men of certain ethnicities.

But regardless of technique, any soft tissue chin work can be done under local/IV sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a facial artery pulsation on my face near my nose that has been bothering me for quite some time now. After reading your case study of facial artery ligation, I would like to get it ligated if possible. It is around the region of my cheek near my nose. I do have a hard time believing its possible to ligate such an important artery as it supplies blood to the skin and tissue of the cheek. If ligation is not possible, I would love to explore the alternatives. Maybe a fat transfer over the artery might work? I would be grateful for you opinion.

A: Please show me a picture of the area on the face where the pulsations exist. The facial tissues have such an extensive blood supply that any single artery ligation does not have a compromising effect. It is more of an issue of how easy is it to get to and would a single point of ligation be effective. Most likely you are talking about a branch of the facial artery as it courses upward around the mouth and the side of the nose. While it can be safely ligated there is the issue of back flow from the tissues that it supplies. Fat transfer for coverage is a good alternative consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for the info on my bad temple implants. I want to remove the temple implants completely and just get cheekbone implants on the arch. But can you tell me, will this have to be two operations? First remove temple implants and then do ct scan to make a model of my cheekbone skull area? Because I want custom cheek implants. I worry if I do both in one operation it will be complicated because the ct scan will show the silicone temple implants (which will be near where the cheek implants will be placed). Do temple implants show up in CT scan? And therefore will the protruding temple implant area show up in the 3D model of the skull that is made from the CT scan? I want to come see you to one remove temple implants completely, and two get custom cheek implants high up on my cheekbone arch. Is that possible?

A: It will not be necessary to do two operations. A 3D CT scan can be done in which the existing temple implants will be seen but they can be electronically removed. Thus custom cheek implants can be made even if your temple implants are present.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking of getting orbital rim implants to improve my lower eye hollows socket area and mainly to raise my lower eyelids so less scleral show is showing…

Can cheek implants placed very high have the same effect of pushing up lower eyelids? Give a less round eye look?

Also will there be lower eyelid retraction after orbital rim implants?

A: It is important to understand that neither orbital rim or cheek implants is going to drive up the lower eyelids to improve scleral show and give the eye less of a rounded eye look. In fact, one of the potential side effects of these implant procedures when done through a lower eyelid approach is lower eyelid retraction. If technically done well and orbicularis muscle resuspension and lateral canthopexies are performed with closure, lower eyelid retraction can be prevented and may even help with less scleral show. But bone-based implants can not push up on the lower eyelid and improve the level of the lash line across the eyeball. The bone levels lie well below the lash line of the eyelid. This is a common misconception which can be verified by pushing up on he cheek tissues and you will see that it does not change the position of the lower eyelid. (unless you really push up far which is not a realistic surgical effect)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like to discuss lip aesthetics. I have noticed that in certain people, their lips in the relaxed, open mouth position, there is a nice exposure of the upper teeth. I would say that this is an attractive trait. 

I would like to posses this feature, but unfortunately, I don’t. When I relax my lips and hang them open slightly, I only feel the my bottom lip hangs and only the bottom row of my teeth show. My upper row teeth do not make an appearance because my upper lip doesn’t move when relaxed. Photos attached,

I have fairly thick lips for a male, so I am looking at getting lip reduction. My question is how to achieve that ‘upper teeth open mouth’ look? Would a lip lift help?

Is there a specific name for this look that I can Google?

A: The procedure yo are seeking does not have a specific name because it is a combination of two well known procedures to try and create the effect you are after. What you need is a combination of a sub nasal lip lift with an upper lip smile line reduction. The lip lift will raise up the central part of the upper lip. (ratio of about 4 :1, meaning for 4mm of skin removed under the nose it will move the smile line level of the upper lip 1mm) Then a horizontal reduction of the vermilion-cutaneous junction of the upper lip of about 4 to 5mms will help raise up the bottom of the upper lip. Together you should be able to develop some natural upper tooth show. The lower lip will, of course, need to be reduced by about 7 to 8mms to match better with the upper lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a septorhinoplasty procedure. I have snoring issues and a previous broken nose. I am curious about price and how much insurance would cover to fix a deviated septum to help with breathing. along with reconstruction surgery to slightly change nose appearance. As far as reconstruction, I would like to make it more defined from the front with a more feminine profile.

A: When it comes to nasal surgery, insurance only provides potential coverage for functional airway issues with the nose. (i.e., breathing difficulties) These include procedures like septoplasty, turbinate reductions and middle vault reconstruction with spreader grafts. Whether they would provide such coverage requires a written pre-determination letter by the evaluating surgeon. For a written pre-determination letter to be considered by the insurance company, a CT scan must first be done to verify that there is internal nasal anatomic derangement. A pre-determination letter that is not accompanied by a CT scan report will be automatically denied.

Insurance will not pay for any cosmetic changes to the outer appearance of the nose. That would be additional costs for the operating room, anesthesia and surgeon’s fee for this type of aesthetic rhinoplasty changes. These are not considered reconstructive regardless of how they developed.

Functional and cosmetic rhinoplasty procedures are commonly done together (septorhinoplasty) with the patient having financial commitments based on the limits of the insurance policy and the extra costs associated with the cosmetic portion. Those exact cost numbers can only be provided now based on what the fees associated with the cosmetic portion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a lip lift question. I’m attaching pictures of myself with and without a smile. I don’t have a problem showing too little teeth when I smile, but when I am just speaking very little of my top teeth show at all. Do you think a lip lift will be of benefit for me?

A: With a very thin lip from one mouth corner to the other, a subnasal lip fit may likely create a pulled central upper lip but still leaving thin sides. This often looks unnatural particularly if one ask the lip lift to do too much. (over lifted) I think your lip is too thin for that procedure to produce an appreciable result and runs the risk of looking unusual. I would have to do some computer imaging to see what it looks like. More likely a lip advancement (vermilion advancement) would produce a more effective and natural looking result. It would also create a more even amount of increased upper tooth show.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about cheek implant removal.I had cheek implants done a little more than  two years ago. They were placed in a way too medial cheek close to my nose next to the paranasal area. They were very big…XXL. I’m 25 years old and I had them yanked out seven months ago. Even though the implants are out I now have this extra volume, edema, or scar tissue like augmentation that looks horrible. iImassage it everyday hoping that it will help to make it go down.

Is there anyway I can ever go back to my original look where I was flat cheeked in that area? Is massaging helping or can i use steroid injections? It looks quite awful because most good looking people rarely ever have volume in this area and its more of a characteristic of old people where cheek soft tissue has moved middle and downwards. 

I understand the risk of steroid injections but at this point i feel like its my only option. I’m quite desperate and don’t want this extra augmentation here to be with me for my whole life since its unsightly.

A: While you can certainly do steroid injections, I would not be optimistic that it will work the way you want it to. Steroids work by breaking down scar tissue. While there is some scar tissue present no doubt, much of the ‘extra’ tissue mass is stretched out normal tissue. Like removing large breast implants, the original breast tissues are stretched out and will never return to normal. The same issue applies with large cheek implants. Whether strategies such as cheek tissue repositioning (moving it laterally and reattaching to the bone would be helpful, I could say without seeing pictures of the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve seen you on real self and seems like you are great with chin implants/surgery. I’ve had a consult with a couple other surgeons…one of them imaged my chin too big. The pic looked ridiculous! I’m wanting to know what you recommend for a female chin augmentation like myself. The other surgeon suggested a 2 or 3 mm implant. I have a chin dimple also. Would the chin implant cover the dimple? If so that would be great because I don’t like the cleft. Thank you!

A: The key to your female chin augmentation, which is not rare for females, is to not use a male chin implant approach. Your chin needs about 3mm (maybe 4mm) horizontal AND some vertical increase as well. That will work best with your vertically shorter total facial height adding more total facial length in a subtle fashion. In addition chin implant should not be round but have a more tapered shape to it to keep the new chin ‘slim’. The chin implant may push out the chin dimple/cleft but I wouldn’t count on it. It is best supplemented with a small amount of injected fat right into the dimple at the same time.

Dr. Barry Eppley

Indianapolis, Indiana