Your Questions

Q: Dr. Eppley, I am in the process of reaching my ideal weight and have been researching tummy tuck surgery I have had two children via c section and I have been over weight/obese for many years. I am currently 5’5″ and weigh 227. I have lost 60 pounds so far but I’m wanting to lose another 40-50. I was wondering when I should start the tummy tuck process with a consult? I know I have a ways to go but I wasn’t sure what the requirements are before having a consult. Do I need to reach a certain BMI or be within so many pounds of my ideal weight? Like I said I’m just researching now and trying to plan for the future. I have double rolls of skin/fat around my abdomen and a lot of sagging already. I’m sure part of that will shrink but I also know I need muscle repair too. Thank you so much for your time and any info you can provide!!

A: Congratulations on your weight loss. This is a great question and a very proactive one. As a general rule when there is weight loss needed before a tummy tuck, one should not have the surgery until one is within 10 to 15 lbs of their weight goal. However, when one is undergoing extreme amounts of weight loss (bariatric surgery or otherwise), one may find that there comes a point when the skin rolls and their ongoing persistence (your skin rolls will not shrink much if at all) will cause one to consider where surgery may need sooner rather than later. I would continue with the weight loss until you hit the proverbial wall and no further change in how you look has become apparent. Then it is time to have a tummy tuck, or what is more likely an extended tummy tuck or body lift, consultation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering how augmentation of the zygomatic arch is done. Is it possible and is it safe to do? It seems that it would not be much different than getting cheek implants.

A: Zygomatic arch augmentation is permanently done by placing an implant from inside the mouth, very much like a cheek implant. (only further back to the temporal bone in front of the ear. This is easiest and most consistently done using a remade implant as opposed to filler, fat or any other type of material injections. Zygomatic arch augmentation can be done alone or in conjunction with the cheek as an extended cheek implant. It is ideally done using a custom made implant for an exacting fit but in some cases may be able to be done using a ‘semi-custom’ approach. (semi-custom means using a custom zygomatic arch design already created for another patient) There is not that much variation in the shape or curve of the zygomatic arch amongst most people.  As you may know there is no specific zygomatic arch implant available off the shelf or premade. So zygomatic arch augmentation must be done by making the implants for each patient. (custom vs semi-custom)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a facelift. I always thought that it would never come to this desire but it has. My goals are to lift my sagging cheeks, reduce the marionette lines some and hopefully ease few wrinkles out of chin. I’m not wanting to look 30… but 55-60 would be nice. I’m going to be making a series of videos of me for my work and the producer wants me to look like a grandma. I would rather look like the kids’ dear auntie. Vanity, vanity….I’ve always known that so I’m good with it.

A: In looking at your three facial rejuvenation goals, they are all exactly what a facelift does NOT improve. A facelift is largely a neck and jowl improving procedure for the lower face. It has not effect at all on the chin, mouth or marionette liens of any significance. It has does not lift the cheeks. Each of your three facial concerns have to be treated by different procedures. Chin skin wrinkles can only be reduced by laser resurfacing, there is no lifting procedure for them. The cheek can be lifted but that has to be done with a cheeklift or midface lift. This is done through the lower eyelid approach so the cheek an be lifted vertically. In some cases, submalar cheek implant can lift sagging cheeks. Your type of deep inverted marionette lines are the most challenging since any type of injectable filler or fat injections will barely make an improvement in them because the line is inverted like a V…this makes it very hard to push out. The best treatment is to excise them and trade-off into a fine smooth line. That would remove them completely but is really done except in older marionette lines that are very deep.

All three of these facial procedures could be performed together and are a lot easier to got through than a traditional facelift.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 23 year old male and i have a concern about my headshape. My head is looking very small on my body, although I have an average circumference of 57 cm at a height of ~180cm. I have a slim face, but the main problem is, that my head gets narrower too much at the top, so it’s a little bit shaped like an egg. I have a long neck and wide shoulders, in combinations of that, it looks just weird. I already read at your page what can be done , but I have still some concerns about getting an implant. Is there a guarantee that it is lasting a life long? Is it as hard as bone, so if someone touches my head will it feel like real skull? And is there a chance that it can move / slip around after some time? I just want to solve this problem and never be confronted with it again, so I am looking for a permanently and safe solution.. What other options do I have if  don’t want to get an implant? Can the bone be restructured, or is it as risky as it sounds?

A: In answer to your skull implants questions:

1) The only safe and effective skull augmentation method is an implant. Moving/expanding the skull bone is not an option in an adult.

1. Skull implants will last a lifetime, will never breakdown or degrade or need to be replaced. They are made of a polymerized silicone material that will only break down at temperatures of greater than 375 degrees F.

1. Skull implants will feel just like bone and will not move around or become displaced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always been insecure about my head shape and I wanted to know what exactly can be done and the cost. I would like a forehead reduction and the back of head reduction as well. I have provided a left and right profile image of my head. Please advise on what can be done. My head isn’t extremely large its just my forehead sticks out too much for my liking and also the back of my head but tell me your honest opinion. Thank you.

A: Thank you for your inquiry and sending your pictures. While both the forehead and back of the head protrusions can be reduced significantly, my concern is the resultant scars from the incisions to do. The back of head reduction  is less of an issue because a relatively small horizontal incision can be made directly over it to reduce it and that scar line always heals very well. The only reasonably acceptable incision to approach the forehead is through a hairline incision right at the edge of the hairline.While that usually also heals very well, it does gove me some pause with your ethnicity and type of hair.

In my opinion the back sticks out further and is more ‘abnormal’ than the forehead but I think you probably feel the opposite about the two…and your opinion is really the only one that counts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know if you can greatly reduce the size of my prominent frontal bossing. This part of my skull that is currently protruding out of my forehead and causing my hair to fall out? Can it be reduced as well as  lower and restore my hairline in the process? The reason I ask this because since my skull expanded my cranial and facial appearance has been altered and I wish to revert this process. If you could please let me know what steps one usually takes from here I would be really grateful.

A: Thank you for your inquiry and sending your pictures. Your frontal bossing can be reduced fairly significantly and the frontal hairline brought forward. How much the frontal bossing can be reduced depends on the thickness of the bone. How much the frontal hairline can be brought forward depends on how much laxity of the scalp exists after it is elevated. While both can be simultaneously accomplished, one issue is that there will be a fine line scar at the edge of the hairline. This is the dual access point for both procedures. Since frontal bossing is not the source of hair loss, the long term consequences of having a fine line scar there and the fate of the hairline in the future bears giving consideration as to its advisability.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I been looking Into skull reshaping procedure for years now, and your website has been very helpful. But I need the back of my skull shaved down but I can’t find no information on numbness? So do this area come with numbness and if so long long can it last?

A: Every time a scalp flap is raised to perform any skull reshaping procedure, whether it be augmentation or reduction, there will be some numbness that will occur over the raised scalp flap areas. Most of this numbness is temporary and is self-resolving over time. I have yet to have a patient tell me that they have any bothersome numbness on the back of their head after any occipital skull reshaping or reduction procedure.

On the back of the head coming up from the sides at the base of the skull are the greater occipital nerves. They supply a lot of the feeling across the back of the head as well as coming further forward along the scalp. These nerves run above the bone in the soft tissues of the scalp. Any type of skull reshaping procedures raises the entire scalp off of the bone, thus the nerves are protected from being injured or cut which would be a cause of permanent numbness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction. Since high school I’ve had a prominent forehead and found it hard to accept. Now ten years later I have decided to do something about it. I have read on your website and checked out the various methods and then decided that the only method that would work for me is directly through the forehead because my hairline is receding. I don’t really have any deep forehead wrinkles but it is the only option. I have attached pictures for your review.

A: Thank you for sending all of your pictures. In regards to the type of forehead reshaping you need the question is whether this is a brow bone reduction (to bring the brow bones back to the level of the upper forehead) or whether it is to build up the forehead above the brow bones to correct its slope. Just based on forehead aesthetics for a male, I am assuming it is the latter. A custom forehead implant is made from a 3D CT scan.

Conversely brow bone reduction can also be done. In your case the brow bone reduction may only be a burring of the most prominent portion of the outer table where it bulges tyhe most.

You are correct in that a limited horizontal forehead incision would be the only reasonable incisional approach. Fortunately custom silicone implants are very flexible (until they situ against bone) and thus can be inserted in a rolled fashion and then unfurled once inside. That at least will keep the horizontal forehead incision more limited, perhaps in the 4 to 5 cm length. The location of the incision would be determined by raising your eyebrows and seeing where the eventual deepest horizontal crease will eventually be. Placing it there will usually lead to a pretty good scar result. The exact same type of incision would be used for any form of brow bone reduction as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation. I have a very odd head shape which really causes me to struggle with every day life. I would seriously consider surgery if It would help me have a more natural looking head shape. I have attached a couple of photos. Ive never spoken to any one about it as no one has that head shape like me and doctors wont be able to do anything and i’ve never seen anything about skull surgery except from the service you offer. I hope you can help.

A: Based on the pictures you have provided, what I see in a flat area on the upper back of the head. If this is your concern, it is not rare in my experience and is the single most common female skull shape concern and surgery that I perform. This is ideally treated by a custom skull implant made from a 3D CT scan. The amount of skull augmentation possible depends on the amount that the scalp can stretch. Usually most natural scalp laxity can accommodate an implant up to 12 to 15mm at its central thickness. Greater amounts of skull augmentation (20mm plus) require a first stage scalp tissue expander to create the looseness and amount of scalp tissue needed to safely cover a thicker implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about jaw angle implants. I recently saw a question on your blog regarding the inevitability of massteric pterygoid sling disruption when there is vertical lengthening of the jaw angle and was wondering if you could elaborate a bit further on the aesthetic impact of this disruption (specifically, the masseter muscle “roll up” that can occur). Does this mean when the jaw is in a normal position, the bulge of the masseter is going to visibly rest higher than the very bottom of the jaw angle? With lengthening of 10-12 mm, is this effect very significant? I was hoping you may have some sort of visual representation of this effect so that it can be more clearly understood – it seems to be a potential negative drawback of too much vertical lengthening.

A: By definition any vertical jaw angle implant lengthening causes some disruption of the masseteric-pterygoid muscle union along the bottom edge of the jawline over the mandibular ramus area. This is inevitable and a consequence of the procedure. But this does not mean that it is always an aesthetic problem. I have done many vertical lengthening jaw angle implants and custom jawline implants (some as long as 25mms), I would say it was only a bothersome aesthetic consequence in less than 10% of the patients.

Disruption of the masseteric pterygoid sling can cause two aesthetic (no functional) problems. When biting down, the bulge of the massteric muscle can be seen to be higher than the actual skeletal/implant jaw angle location. Or they can be persistent fullness above the jaw angle that prevents a well defined jaw angle definition (or flare of the jaw angle) to be seen. There is no way to predict beforehand what type of vertical lengthening jaw angle implant patient this aesthetic sequelae may be seen in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about temporal artery ligation. I have two prominent vessels on my temples. They are actually not veins. It’s a temporal artery on both sides of my head. I’ve spoken with two doctors who said to leave it alone. Here are pictures of them. I was told these are arteries, not veins. Both doctors told me that they should not be removed as they supply blood flow. Sometimes they’re not very visible but that’s usually when I’ve just woken up in the morning. I have a little bit of high blood pressure and I’m on medication for it. Anyhow, I’m not really sure what to do. I didn’t have these a few years ago but as I’ve gotten older they’ve gotten worse. I really don’t want to have permanent scars from a procedure.Thanks.

A: Thank you for sending your temporal pictures. These are classic enlarged anterior temporal branch arteries from the bifurcation of the main trunk of these superficial temporal artery. They will be more noticeable with your blood pressure is higher, when exercising or when in hotter temperatures due to the increased blood flow in them. Whether you have them treated by temporal artery ligation to reduce their visibility is a personal decision. But if you were to do so, this is a perfectly safe procedure that is done through very small incisions in the temporal hairline and possible a very tiny one at its end at the side of the forehead. These small incisions do not create scarring concerns. The forehead and scalp have such a redundant and extensive network of blood supply that reducing flow through these vessels will not cause an harm in so doing.

Dr. Barry Eppley
Indianalpolis, Indiana

Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had my primary rhinoplasty done six months ago. The method used was diced ear cartilage wrapped in fascia to increase bridge and tip height. What I’ve noticed in my bridge is that it slightly decreased in height possibly due to swelling going away. With the swelling gone, the bridge height isn’t as augmented as I had wanted. For a revision,I wanted to know if Dr. Eppley would consider using the diced cartilage injection technique.Looking for very slight increase in bridge height.I feel that cartilage injection best suits my case.That minor change can make a huge difference. As I have read in some of your articles concerning revision rhinoplasty, many patients desire a revision rhinoplasty because they may be seeking the optimal look for themselves and may not be a result of aesthetic unhappiness with what their previous surgeon performed. In my case, I feel as if my surgeon did an excellent job with my rhinoplasty. My only issue now is that I was extremely gratified in the first three to four weeks with my nose but failed to realize that the swelling played a role in that. Now that the swelling has almost subsided completely, I am looking to add enough bridge height to replicate what it looked like in the first month post surgery. I can’t stress to you enough how little of an increase in bridge height I am desiring, but it’s enough of a change to make a huge difference for me. 

A: Thank you for our detailed rhinoplasty history. For a modest increase in dorsal height, I would agree that an injection of diced cartilage, done through an intercartlaginous incision, should be appropriate.While the concept of an injection always sound simple, it is important to note that cartilage must be harvested, prepared and then injected. The question is where that cartilage should come from…the contralateral ear or the septum?  Either way this usually requires more than a local anesthetic in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am seeking a facial profile enhancement. I am not happy with the way my profile looks. I would like your recommendation. I have a deviated septum so a rhinoplasty at the same time might be possible? I also have an overbite and I was wondering what you would recommend for receding chin… orthodontics or cosmetic surgery.

A: It is very common to do a septoplasty and rhinoplasty at the same time, known as a septorhinoplasty. You do have a short chin and treating its deficiency combined with neck liposuction would provide the best result. With an existing overbite the question is how significant it is and whether you are prepared for the commitment of a combined orthodontic-jaw advancement surgery treatment program. (orthognathic surgery) If not then a chin implant or sliding genioplasty would be the cosmetic treatment options. A rhinoplasty, chin augmentation and neck liposuction could all be done at the same time for a significant facial profile change. (facial profile enhancement)

A combination of nose, chin and neck changes can make for the most powerful and significant change in one’s facial profile that is possible. It usually takes at least two changes in one’;s face to create the optimal facial profile enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom skull implant. The back top of my head is flat and I plan to do something about it. my questions are the following:

1. what materials are available and what would you recommend?

2. will the implant affect hair growth, (in some way?)

3. what is the cost and time to recover?

4. side effect, pros-cons ?

I greatly if you can answer these questions for me and looking forward to hearing from you!

A: In answer to your custom skull implant questions:

1) By far the best method of skull augmentation is a custom made silicone implant fabricated from the patient’s 3D CT scan.

2) Skull augmentation with a subperiosteally placed custom skull implant does not affect scalp hair growth.

3) My assistant will pass along the cost of surgery to you on Monday. Recovery is fairly quick with minimal downtown other than some scalp swelling and some mild discomfort.

4) The benefits to a custom skull implant is that it is best method to get the smoothest and greatest amount of skull augmentation with the smallest incision. Its downsides are that it does require an incision to place it (7 to 9 cms long) and may or may not be able to achieve the desired amount of skull augmentation as a single stage procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a forehead widening and brow bone implant. Is it possible to get a wider forehead like in the attached picture and a brow bone similar to the one in the second atached picture in one combined procedure?

A: Such forehead and brow bone changes are possible under the following two circumstances;

1) a custom forehead implant with a brow bone extension must be used which is designed off of a 3D CT scan of the patient, and

2) a coronal scalp incision would be needed and the resultant fine line scar for its placement.

While smaller brow bone implants can be placed through small scalp incisions using an endoscopic technique, as soon as the larger forehead component is needed a much larger open scalp incision is needed to ensure proper placement.

The wider forehead comes from making the custom forehead implant extend beyond the anterior temporal lines on the side of the forehead. In essence the the implant creates a new temporal line more lateral to the existing one. This also requires that the implant extend down inferiorly on top of the temporalis fascia into a fine feathered edge so that there is no visible implant edge transition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My rhinoplasty is tricky as my stiff columella is my main complaint. wonder if the actual columella bone can be shaved without addressing the tip of the nose.  I have read about anterior nasal spine reduction but I am not sure what that is. I am open to suggestion.

A: The reason that your columella is so stiff is that you have a prominent anterior nasal spine. This is what you refer to as the ‘columellar bone’. The end of the nasal septum, which sits behind the columella of the nose, rests on the anterior nasal spine. The longer and more prominent the anterior nasal spine is on the maxillary bone, the more forward will sit the end of the septum. This causes a very open nasolabial angle (angle between the base of the nose and the upper lip which inn most men should be about 90 to 95 degrees) and a very firm and stiff feeling columella. The anterior nasal spine reduction procedure removes the bony prominence  and the base of the end of the cartilaginois septum that attaches to it will allow the nasolabial angle to sit back, decreasing the tension on the columella and the upper lip. This can be done by itself or one of the many maneuvers in an overall rhinoplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want a reductionrhinoplasty that will really make my nose smaller. I have attached a picture which shows how much reduction I want. Is this possible?

A: The limitations of a reduction rhinoplasty are largely skin thickness based. In thick skin more major support reduction (osteocartilaginous structures) can be met with ‘skin resistance’. This is most manifest in the nasal tip area where thick skin has a propensity to ball up rather the than shrink down.  This results in not the desired tip refinement but a persistent wide ill defined tip despite what has been done to the tip cartilages underneath. The amount of nasal reduction you are illustrating overall I do not think is a realistic one and certainly not an advised one. Your nasal skin is thick not thin and your tip area will likely suffer the very complication of which I just described. While I do computer imaging with  the most conservative change possible, so as not to over promise any result and it is likely more reduction/refinement may occur that what is shown, I know that what you are desiring can not be achieved. At best in my hands the result may be halfway between what I have imaged and the amount of overall nose reduction you are desiring.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, What is the cost of start to finish with Breast Augmentation. I am concerned that I may need a breast lift as well but I see you have a before and after photo on your website when you click on the breast tab and below its says large breast implants there is a female on the left that is very comparable to my breast structure and looks like she just had implants and looks amazing. That’s what I am looking for. I am 27 years old with one child now with extra skin. Thanks

A: The critical question is whether you need a breast lift with your implants or not. That, of course, would impact the results as well as the cost of the surgery.if you could send some pictures of your breasts I could make that determination. The other issue that can tip the balance for or against the need for a breast lift is the final size of the breasts one desires. In some cases, large breast implants can overcome mild to moderate amounts of breast sagging with the considerable volumetric expansion. But that depends on the position of the nipple to the inframammary fold. Large volumetric expansion (large breast implants) works to create a breast lift IF the nipple is at the level of the inframammary fold or higher.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am jnterested in rib removal surgery.I will like to slim my waist. I’m a bikini fitness competitor and my waist is very width. Off season (photo) I have 70 cm, in season I have 67 cm. I don’t know is there is another procedure that can help me slim my waist. I have been researching about ribs removal and I want to know how much time I could not exercise. And the most important question is how much could I slim my waist?

A: Given your picture I would agree that I don’t see anything else you could do on your own to narrow your waist any further. I suspect rib removal surgery could probably achieve a waistline reduction down to 62 to 64 cm in circumference . Time off from exercise would be totally dependent on how you feel but would most definitely be two to three weeks. There are no restrictions after surgery. You let your body tell you when to do any physical activities.

Rib removal surgery does leave a fine line scar as a residue from the procedure. So one has to be certain that aesthetic trade-off is a worthwhile one for the amount of waistline reduction seen.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in transgender buttock implants. I’m looking for assistance in achieving an hourglass figure, fat transfer and/or liposuction are not an option as I have always had minimal body fat. I know that some surgeons do not like to operate on transgender women. I am transgender, and have lived “full time” for more than 15 years. In this time I have worn padding to give the effect that i am looking for. The result is that I hate my naked, boyish hips and behind. I would like someday to be able to not have to wear padding and just have the body I have always desired. It doesn’t have to be perfect. I’m not expecting rainbows and unicorns, but I don’t think I am asking for the moon, either. Can you help me? thank you

A: With a thin straight body you are correct in that only implants can potentially make positive buttock and hip changes. Usually both buttock and hip implants are needed as buttock implants don’t extend to the hips and vice versa. I would be interested to see what amount of padding you use to create the optimal augmentation effects. Knowing what type of buttock enlargement change you are looking for will determine whether your buttock implants should be in the intramuscular or the subfascial location.

Most transgender buttock implants are often done in the intramuscular location since the amount of buttock enlargement desired is usually not extremely large.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year old female who was on the oral bisphosphonate, Actonel, for about 5 years. I last took this medication about 5 years ago. I had a CTX test done in October (level was 215), because I was contemplating jaw surgery to correct a midline issue. Neither local oral surgeons who I consulted with felt comfortable doing the surgery for cosmetic purposes. I have since gotten into braces to correct the issue. My concern with genioplasty is whether the same risk level is present for osteonecrosis as exists with jaw surgery. Any thoughts would be appreciated.

A: Since the chin is part of the jaw, the same potential risks exists for it as any other part of the jaw for bisphosphonate patients in regards to developing jaw osteoradionecrosis from a surgical insult. Poor bone healing has been reported for genioplasty on bisphosphonate patients

However, the CTX (serum C-terminal telopeptide) blood test is used as a predictor of that risk which assesses how well the bone can remodel and heal. The risk stratification is seen as high risk at less than 100, moderate risk between 100 to 150 and minimal risk above 150. It is also known that the longer one is off the drug the CTX values will increase at a rate 1/month. This explains your favorable CTX value five or more years off the drug.

While no one can say that your  jaw osteoradionecrosis risk is zero, it would be considered minimal at this point.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant replacements. I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?

A: Thank you for sending your pictures and questions about cheek implant replacements. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullneess below the cheek bone which does not work well in your face. I would recommend the following:

1) Remove existing submalar cheek implants.

2) Your new cheek implant style would be any form of a combo or one that has no submalar component at all.

3) You need ‘high’ malar augmentation style implants that also go back further onto the zygomatic arch. No such standard malar cheek implants exists, even amongst the standard malar options. Ideally a custom cheek implant style is made that would fit your face precisely and create the augmentation exactly where it is needed. Because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.

4) If I was ‘forced’ to use a standard cheek implant I would use the malar shell style and modify it during surgery.

5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 female with bad dark circles. I would like to have hyaluraunic acid injectable filler to improve the look of my under eyes. I have attached some pictures without makeup for your consideration. I have never had any procedure performed before. Am I a good candidate for the under eye filler? Also, could you please let me know the cost of the procedure. Many thanks.

A: Thank you for your inquiry. A hyaluronic-based injectable filler is a good place to start for your dark circles under eye issues even though it is not the best treatment for it. It is important that you understand that any filling of the under eye hollows is not going to solve your hyperpigmentation problem. It will improve the hollows but that alone will not make the dark color go away. Ideally you would treat them with fat injections combined with a peel of the skin with pre- and post treatment topical hydroquinone. But starting with a temporary filler will determine for you whether the correction of the hollows alone can be done by injection of any material and is a ‘pre-test’ for future fat injections which are superior in terms of both volume retention and potentially aiding in the hyperpigmentation issue.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I understand that you are the inventor of the Brink Peri-Pyriform implant. I am writing you to inform you that this implant improved my speech and my life. I am American-born Chinese, and English is my native language. However, until I had the Peri-Pyriform implant put in, I always had a significant amount of difficulty speaking fluently and clearly.

All of my life, people have often told me that they could not hear, or make out, what I was saying, or that it seemed like I spoke with an “Asian American accent.” Several years ago, I noticed that words containing “ch”, “sh”, “j”, “zh”, “n”, and “r” sounds were especially difficult for me to articulate. I also began to notice that many other Asian people, both native and non-native English speakers, also exhibited these speech characteristics to varying degrees. Furthermore, as I am sure you already know, Asians typically have shorter head lengths than do people of other races.

This led me to a theory: In Asians whose head lengths are particularly short, separation between the upper lip and the premaxilla impairs articulation of the speech sounds “ch”, “sh”, “j”, “zh”, “n”, and “r”, and this, in turn, impairs significantly the articulation of words and sentences containing these sounds in English and French, and possibly in other phonetically similar languages.

Shortly after coming up with this theory, I had premaxillary augmentation surgery using the Peri-Pyriform implant. Immediately after the surgery, my articulation of those sounds was improved, as well as my clarity in speaking.I had always been very quiet. Now that I can speak more fluently and clearly, I am less shy about speaking, and I have a much happier disposition. Hopefully, others like me will also be able to benefit from the Peri-Pyriform implant.

A: Thank you for your relaying your experience with implant augmentation of the pyriform aperture region. I have to confess that I did not do the original design of the implant, that credit goes to Dr. Brink as indicated in the implant product’s name/description. I do have a lot of experience with this facial implant, however, and most of that is in Asian patients for the facial shape reasons you have described.

Of all the potential benefits of a Peri-Pyriform implant, speech improvement is not one I have ever heard of or could envision occurring. Your anatomic explanation/theory sounds perfectly plausible however as it can cause greater upper lip projection, particularly at the nasolabial area. That may improve upper lip contact with the lower lip which may help in articulation with certain sounds.

Regardless of how it may have helped, you are living proof that it indeed has. I could not be more happier for you that such a simple facial procedure could have been so helpful.

Thanks again for taking the time to share your most fascinating facial implant experience,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a breast implant exchange. I want to change from Mentor moderate plus silicone breast implants to moderate classic profile silicone implants with the same submuscular placement.(dual plane) I want only Mentor smooth round moderate classic profiles in size 385cc or 405cc. I want the most natural natural results with no upper pole fullness. I currently have Mentor 325cc and It is still not natural enough for me. I don’t want to look like I have breast implants.

A: From a breast implant exchange standpoint, changing the profile from moderate plus to a moderate profile will help a little bit bit I suspect not as much as you would like. The best way to maximally decrease upper pole fullness would be an anatomic or shaped breast implant since the shell is designed to distribute 2/3s of the implant’s volume in the lower pole. But smooth silicone implants offers a slightly lower expense to this aesthetic concern so this is an economic choice. But certainly the breast implant exchange as you have proposed can be done.

The interesting question, regardless of the breast implant profile, is how going up in size may work against the very goal you are trying to achieve…a natural look. i suspect that  lowering the implant profile while simultaneously increasing implant size have you ending up right where you started… too much upper pole fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m concerned about my right buttock implant. I had large buttock implants (625ccs) placed above the muscle about one year ago. My right buttock implant seems to be lower than my left and it seems to continue dropping. As shown in the attached pictures the left is the perfect buttock while the right is not so perfect. What are my options to correct this without another surgery or spending thousands of dollars?

A: Like all implant asymmetry issues anywhere on the body or face, there are never any non-surgical solutions to their repositioning or adjustment. But to provide a more wholesome perspective, let’s review why you have what you have and what you would do if the concept of another surgery or economics were not an impediment to the desire for improvement.

Buttocks implants in the subfascial plane (above the muscle) have a known propensity to potentially drop as they heal and settle. This is quite unlike intramuscular buttock implants which stay locked in a high pocket because of their tight muscular confinement. At 625cc implant size, this was never an option for you since the largest implant in the intramuscular pocket at your height would be about 350cc to 400c maximum. In the subfascial plane, all the surgeon can do is place them in what appears to be a high pocket knowing that they will settle. Why one implant eventually settles lower than the other one, like in your case, is unknown and unpredictable. Why it may do so even at a late period after surgery is also unknown. The size of the implants may have something to do with it but then the one buttock implant is fine….so clearly size alone is not the sole driving factor. Whether any further dropping may occur is also not known but there is a limit as to how how low it can go and I suspect you have likely reached it.

Correction of buttock implant asymmetry, unlike that of breast implants, is neither easy or assured. Repositioning of a low breast implant, for example, is comparatively easier since the access point (the incision) is at a convenient position on the underside of the breast and the pocket can be sutured upward. Such is not the case with buttock implants where the access point is from above. The implant would have to be removed and the pocket attempted to be sutured from far away through a small incision and the implant re-inserted. This is a very difficult surgery and the retention of the pocket elevation very unlikely given that one has to sit on it at some point after surgery. While it can be done, success with upward buttock implant respositioning is usually very low.

While buttock implant asymmetry is not a desired aesthetic outcome, the risks of revisional surgery may outweigh any effort in that regard. Besides the low probability of success, entering a healed implant pocket always induces the potential risk of infection. Should infection occur, which is always more likely in subfascial vs. intramuscular pockets, the aesthetic outcome would be disastrous with loss of the implant.

Putting all of this in perspective, living with some buttock implant asymmetry may be the only economic choice, it may also be the best medical decision also.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about custom facial implants.

1. How long is the standard recovery process after chin/jaw surgery? Is one week reasonable to plan? Please note, I´m not looking for an exact number of days, only an estimation.

2. The webpages you provided, while helpful in delineating different procedures, do not offer much insight into Dr. Eppley´s expertise vis-a-vis chin/jaw custom facial implants. Hence: how many of these surgeries does he perform per year?

3.  What is success rate of these procedures, purely in terms of patient satisfaction?

4.  How high/serious is the risk of infection or asymmetry?

5.  In the event of infection, does implant have to be removed? If so, will my stay have to be prolonged? Should the new surgery be required – who covers the new expenses?

A:  In answer to your questions in regards about custom facial implants:

1. It depends on how one defines recovery. Full recovery with all swelling gone will take a full six weeks. 50% of the swelling is gone by 10 days so a one week recovery would not be realistic in terms of appearance.

2. I perform over 100 semi-custom and custom facial implants per year, more than most any other surgeon in the world.

3. All of these procedures are successful. The better question is how many revisions are performed due to aesthetic concerns. (10% to 20%)

4. I have never seen an infection. Custom facial implants minimize the risk of asymmetry significantly..

5. The expenses of revisional surgery of custom facial implants, for whatever reason, are the responsibility of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I stumbled upon your case study for vertical orbital dystopia when researching potential corrective procedures for just that. I’m a 27 year old male who has orbital dystopia with about the same severity as the guy in your study and I’m curious what the ballpark price would be for such a procedure. I’ll gladly send you a picture, or provide you with any other information you might need.

A: Thank you sending your pictures. It appears you have about a 5mm horizontal discrepancy as based on the position of the pupils. The is probably just within the range of what can be improved by an orbital floor/orbital rim augmentation procedure. This can be accomplished by either using hydroxyapatite cement for the buildup or using a 3D CT scan to make a custom implant.

The bony augmentation aside, the real key to a successful aesthetic outcome in vertical orbital dystopia is how the lower eyelid is managed. For the lower eyelid must be elevated with the globe or an increased amount of scleral show will result. At the least this requires a lateral canthoplasty, which may or may not, require a mucosal spacer graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I notice you also do a surgery that can increase the width of your mouth. (mouth widening surgery) Can this be combined with a corner lip lift? Also does the procedure that increases the size of the mouth help the smile out? I notice when I smile I only have about 4 teeth showing on each side not because of the way my teeth are but because of how narrow my smile is. It just doesn’t stretch nearly as far as I would want it to. Would a wide mouth surgery give me more of a cheshire cat grin where I would be able to expose more teeth on the sides?

A: A mouth widening procedure can be combined with a corner of the mouth lift. It is just how the angle of the mouth widening is positioned to create that effect. A mouth widening procedure has a static effect, not a dynamic one. It is the pull of the zygomaticus and upper lip muscles that drives the corner of the mouth and the upper lip upward and outward to expose the teeth. It is not how wide the distance between the mouth corners are that has the biggest effect. Thus, I would not expect much improvement in tooth show just with a mouth widening procedure. But it certainly will not hurt and may have some small improvement in tooth show.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in occipital knob reduction surgery. I have an occipital knob I would like removed on the back of my head. My initial questions are:

1) would I need to arrange a scan or something similar over here to send to you or would you be able to see enough from pictures I can provide to determine whether I am a suitable candidate for this surgery? 

2) is this surgery only performed under general anaesthesia, could it be performed under twilight or local even? 

3) what are the potential risks of the surgery?

A: No x-ray or preoperative visit is needed for the occipital knob reduction procedure. Pictures alone are all the preoperative information that I need which you can send to me at any time. The surgery is done in the prone position (face down) and the occipital region is virtually impossible to adequately make numb by local anesthetic to adequately perform the procedure. IV sedation can not be performed in the prone position due to inadequate protection of the airway. Thus general anesthesia must be used for the occipital knob reduction procedure. The only minor risk, and an expected one, is the small horizontal scalp incision/scar used to perform the procedure.

Dr. Barry Eppley

Indianapolis, Indiana