Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting deltoid implants. I am a 36 years old male and I have very short clavicles and a larger than average head to make my shoulders appear even more narrow. I have read a response to a deltoid implant question it made me come up with a few questions.
1. The response stated that the implants can be place in a intramuscular location. Does that apply to an implant for both lateral and posterior deltoid heads? If not, what type of deltoid implant can be placed in the muscle?
2. How much actual width could be added using the largest implant possible without effecting practical functions (such as lifting the arms sideways)? I attached a picture of my narrow shoulder along with a photo-reference of a look I’m going for. I’ve provided of a picture of the look I’m trying to achieve with surgery. The red area is what would be the ideal mass added with an implant. Would this be possible?
A: When it comes to deltoid implants, an understanding of the anatomy is important when considering implant placement. The deltoid muscle is a broad muscle that creates the rounded contour of the shoulder. While it technically has three sections or muscle bellies (anterior, central and posterior), it is best to surgically think if it as single muscle belly as they are difficult to separate. The muscle is also enveloped by a fascial lining that is most manifest on its outer surface. Thus implants can be placed either submuscular (under the muscle) or subfascial. (above the muscle but under the fascia)
When considering where to place a deltoid implant, one has to take into consideration the movement of the muscle and the arm. As the arm lifts away from the body, the deltoid muscle contracts and becomes shorter. There is the risk, therefore, that a submuscular implant placed directly under the central belly of the muscle could interfere with arm motion. This would be less true for a very small implant or one that is placed closer to the front or back edge of muscle, but this then would not have much of a visible effect as you desire. This makes the subfascial location preferred in most cases.
Lastly there is the issue of incision location to place a deltoid implant. This is almost always best done on the back side of the arm where it meeds the trunk, keeping any scarring in the least visible location.
Your photo reference indicates a result that probably can not be achieved. Maybe half to three-quarters of that amount of shoulder augmentation is more realistic. Think of adding about 1 to 1.5cms width per side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in depressor septi muscle surgery. When I smile the tip of my nose really gets pulled down. Also my upper lip crunches up and a wrinkle appears across the top of my upper lip. I have read online that this is due to a muscle under the nose and if it is released my nose and lip will look better when I smile. How is this surgery done?
A: The muscle you are referring to is the depressor septi muscle. It is attached from the upper jaw at the base of the nose upwards where it attaches to the nasal septum and the back part of the nasalis muscle. It is this muscle then when overactive pulls the tip of the nose down an pulls up on the upper lip which sort of crunches the nose and lip together. In rhinoplasty this is known as the smiling deformity.
This smiling deformity is often treated at the time of a rhinoplasty or can be done as an isolated procedure. The surgical techniques for treating an overactive depressor septi nasi muscle vary and consist of either an(intranasal resection or an intraoral release/transposition. A recent study has shown that the both techniques produce similar effects in how much they decreased the effects of smiling on the length of the nose, tip projection or upper lip length.
The intranasal approach is historically more common due to the anatomic location of the muscle when doing a closed rhinoplasty. It has a side benefit of decreasing the interalar distance. The intraoral approach has been more recently described undoubtably due to the now widespread use of open rhinoplasty. Coming from below (inside the mouth) allows an actual release and transposition of the paired muscles. This results in an increased fullness to the upper lip afterwards.
Either depressor septi muscle surgery techique can be done under local or IV sedation and has a minimal recovery with some short-term upper lip swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently struggling with a flat back of the head and a small head too. Can skull reshaping surgery be done on me to add any implant to mainly the back and top parts of my skull that would give me a decent sized head that is also well rounded ? How effective is this surgical procedure and what are the possible negative effects of any implant on my actual skull?
A: Skull reshaping (augmenting a flat area) can be done to almost any part of the skull and its limits are based on how much the scalp can stretch to accommodate the volume of augmentation. Based on what one’s expectations are, it can be a highly effective procedure. I would have to see some pictures of your head that show the flatness and then do some computer imaging to see if what skull augmentation can do is sufficient. It is always important before surgery to find out if the changes meet a patient’s expectations and to determine how much volume is needed to create that augmented effect.
There are no known long-term effects of the materials used in skull augmentation as it relates to the bone or the overlying scalp tissues. Bone resorption is not known to occur nor is scalp thinning over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding chin reduction. Could my chin be reduced in height vertically with out having my chin split into pieces? I think that is too much of a risk and to much time to recover from for me. Is there something else you can possibly do like burr it upwards from underneath as well as backwards because I have what I consider to be a pointed chin. I would like to have it rasp to the point it looks wider, flatter and shorter. Is this surgery at all available? How much is allowed to be vertically shaved off before it reaches into the too much taking off zone? I would prefer the incision inside my mouth being as though I’m a person of color but I’m willing to take that risk to have the chin exposed through the under cut to obtain the result I so desperately desire. I’ll just get my scar revised if that’s what it takes.
A: The type of chin reduction you are referring to is common and is known as a submental chin reduction. While burring is used for some minor shaping, more significant reduction is done by a saw blade cut and the edges then burred. This can make a radical reduction in vertical chin length and definitely can take a pointy chin and make it shorter, wider and flatter. With this much vertical chin reduction, the submental approach is best anyway because it allows the excess soft tissue to be removed and tightened as well to prevent a witch’s chin deformity. The amount of bone reduction that can be done is based on the location of the tooth roots and the exit of the mental nerve which is usually above the 10 to 12mm mark from the lower edge of the chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a Brazilian Butt Lift. Could this procedure include having liposuction for weight loss reasons as well as butt enlargement? It seems like you get two benefits at once, a bigger butt and dropping your weight at the same time.
A: Every Brazilian Butt Lift requires liposuction to harvest the fat that needs to be transferred by injection into the buttocks. This almost always comes from the abdomen, flanks and waistline and as much fat is taken as possible in most cases. But to call this liposuction harvest, or any liposuction procedure, a weight loss method would not be appropriate. That is not what it accomplishes. Liposuction is a shaping technique but it does not create any substantial or sustained weight loss in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i want my forehead made smaller with a shorter hairline. I would like to have a procedure at your facility to have the central frontal bone vault reduced to about 5mm and the glabella the triangular area in between the eyes over the nose and under the brows,I had a interview with a previous surgeon who was actually to far from me to travel but he was saying my scalp is flexible Enough to bring it down to 2 cmd maybe another half once he loosened this area underneath my scalp. I forgot the name of it,do you have any idea what he’s referring to and do you use this same technique?
A: You are referring to a hairline advancement procedure as part of an overall forehead reduction. This requires the scalp be loosed up so it can be brought forward and the hairline lowered. The more natural scalp flexibility one has, the easier and more hairline advancement that can be achieved. This is often done with frontal bone remodeling such as frontal bone reduction and some brow reshaping/contouring. You are correct in assuming that about 5mms of frontal bone can be safely reduced by burring.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young man and I am embarrassed of the shape of my head. My head circumference is about 58 cm which seems to be only about 1-2 cm more than the average but the shape is abnormal- as it gets wider above the ears and temples on both sides. What is very surprising when I clench my jaw both sides of the head gets wider (about 0.5 cm) each side, and when I widely open my mouth both sides of the head get thinner and head looks almost normal. Would you be so kind to answer my questions. Is there any possibility to reshape my head on both sides. If yes what is the potential risk of such surgery- is there any chance to damage my brain, nerves, veins etc and is such surgery a big risk for my health and life? Does the surgery may affect in a bad way circulation of the blood in my head which my cause for example hair loss (it is extremely important for me to protect my hair because that is the only way I can mask shape of the head). What is the recovery time? I train bodybuilding and boxing especially the second one is obviously extremely contact sport- will I be able to continue my two passions and how long after surgery will I be able to come back to training?
A: What you are describing perfectly are thick temporalis muscles which is making a major contribution to the width that you are seeing above your ears and into the temple region. This is evidenced by the widening effect that occurs when you clench your teeth together (temporalis bulging) and why it gets thinner when you open your mouth. (stretches and thins the temporalis muscle) This dynamic head width changes indicate that a temporal reduction (temporalis muscle shortening/relocation procedure) would be very effective. This results in a 5 to 7mm change per side (1.0 to 1.5 cms transversely combined) when these muscles are shortened. In addition a small amount of bone burring can be done at the same time. Not that you know the correct procedure, the answer to your questions are as follows:
1) There is no risk to your brain or any major blood vessels or nerves.
2) There is no risk to your general health. This is an aesthetic operation.
3) This surgery does not affect the circulation to your scalp or head.
4) There is no risk of any hair loss.
5) The recovery is fairly quick, just some swelling on the sides of the head that looks pretty normal in a wee. There are no restrictions after surgery.
6) You could return to contact sports within two weeks after surgery.
7) I will have my assistant Camille pass along the cost of the surgery to you later today.
The biggest issue in performing temporalis reduction surgery is that fine line incisions are needed on the side of your head to perform it. These incisions do not cause any hair loss and I do not shave the incision line to perform them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation surgery but needs some basic recovery questions answered. What is the average time you recommend returning to work? I already have dates that I’m taking off for this year for vacation and other things, so I don’t want to have to take too much time off work. Also, I have an 18 month old, and she is a big girl for her age right now! She is a momma’s girl and is always wanting me to hold her and carry her, so my other concern was being able to lift her and carry her. What are your lifting requirements after surgery?
A: Returning to work after breast augmentation is highly variable based on what one does, how physical their job is and their own discomfort tolerance. On average, it can be anywhere from 3 to 5 days. I place patients on arm range of motion exercises the night of surgery and the more you move the quicker you will recover. I have no lifting restrictions after surgery and you can lift anything you want without fear of hurting the result. Your body will tell you what you can and cannot do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in deltoid implants. I am a 25 year-old male who has done bodybuilding for the past two years with great results. This is with the exception of my deltoid muscles, which are one of the most important and prominent muscles on a male body. My dad has also weak shoulder muscles so I think it’s genetics.
Now my questions:
1. How are the (silicone ?) implants placed and where exactly, so that the most obvious effect in width is achieved ? Are they placed into the muscles or above, because one should not feel the material when one touch the shoulders if possible.
2. How thick are they? How much shoulder width can be added with the implants ?
3. What are the risks during and after such a surgery?
4. Is the result permanent?
A: In answer to your questions about deltoid implants:
1) They are silicone implants and are placed either subfascial or intramuscular, depending on which head of the deltoid is being augmented. Of the three heads of the deltoid, the most commonly augmented are the lateral and posterior heads with the implant placed between them. This also creates the greatest amount of width augmentation. It would be helpful to see exactly by pictures which areas of the deltoid you want augmented.
2) Since there are no real deltoid implants commercially made, I use calf implants which have three sizes (volumes 70 to 170ccs) with up to 2 cm of thickness per implant.
3) The risks of surgery are a permanent scar, infection, undercorrection/overcorrection, and implant malposition. (which are the standard risks of any implant-related surgery)
4) The implants will never degrade or breakdown and thus add permanent muscle augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. As you can see from my attached pictures, I have a bulbous tip and a deviated septum. I hope to reduce the bulbous tip as well as straighten my nose. Can you please notify me if this can be done? Also from the pictures can you tell me whether or not I have thick nose skin? If I do have thick skin, will I still be able to reduce my bulbous tip and gain a more straighter profile on my nose?
A: I think you are an excellent candidate for rhinoplasty. You have a wide bulbous tip with played domes of the lower alar cartilages with intervening fat. But it should shape up nicely with an open rhinoplasty where the cartilages can be reshaped and brought together to create a much more narrow tip with more refined definition. I do not see that the thickness of your skin as being a limiting problem for getting a good rhinoplasty result. You have intermediate skin thickness which will shrink nicely when the underlying cartilages are reshaped.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry correction. My face is crooked, particularly my chin and jaw. When I smile my chin pulls to the left and makes the jaw asymmetry look worse as it points to the left. The rest if my face on the left side is also uneven. My left eye and eyebrow are lower and my cheekbone seems smaller. When I look in the mirror I don’t look too bad but it looks much worse obvious in pictures. Can my facial asymmetry be fixed?
A: Like many cases of facial asymmetry, it rarely is just one area of the face. What you are describing is a more complete unilateral or one-sided facial underdevelopment. This is evidenced by a lower eyebrow and eyeball position, a flatter cheek and a shorter jawline distance from chin back to the jaw angles. In essence the vertical length of the face is shorter on your left side than your right. The jaw asymmetry in particular is magnified when you smile as the soft tissue of the chin is pulled back and deviates to the less developed side.
There are a variety of facial asymmetry procedures that can be done from the eyebrow down to the jawline. What you would do depends on how much of the facial asymmetry you want to treat. The chin/jawline often displays the most severe aspects of facial asymmetry and is often the most important area for many patients to correct. This can be treated by a sliding genioplasty to realign the bony chin to the midline. This can be possibly combined with a small jaw angle implant in the back to completely lengthen the entire jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How much will a rhinoplasty surgery cost me? I have Aetna Insurance and I want to know how much they might cover. By the way I have breathing issues and I went to a doctor and he told me my septum needs correction and my insurance might cover half of the whole surgery price.
A: Let me provide you with some clarification on your nose surgery and a better understanding about the costs of such surgery. The concept the ‘insurance may pay half of the whole cost of the procedure’ is both misinformed and overly simplistic.
What you are seeking is a nose procedure known as a septorhinoplasty. This is a procedure that combines the correction of a functional problem (septum and turbinates) and an aesthetic nasal issue. (rhinoplasty) While they are commonly done together and one does affect the other one, they are viewed economically as two separate issues no matter where you are having the procedure performed. The septum and turbinates are functional airway issues and are often covered by insurance. The rhinoplasty is an aesthetic issue and is never covered by insurance for common aesthetic reasons. Just because the two procedures are done together does not in any way mean that insurance is covering any cost of the rhinoplasty. Those fees must be paid out of pocket and in advance and includes the surgeon’s fee and the operating room and anesthesiologist’s time to do it. When done together a surgeon may choose to lower their professional fee for the rhinoplasty as a courtesy although they are under no obligation to do so.
Thus the only thing that insurance covers has nothing to do with the rhinoplasty. And if you do not do careful financial analysis beforehand (how much is your deductible, what is your percentage of costs beyond a certain dollar amount of what insurance pays), you could easily end up paying more for the whole procedure using insurance than if you paid the entire septorhinoplasty as a complete cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I am wondering what all can be done to make my forehead go more up and down rather than how it slants severely back starting immediately above my eyes. After looking up pictures and seeing people with different types of foreheads I think I have found the answer to my problem, or rather, what I would desire to have for myself. I just don’t know how much can actually be done in the present time and how realistic my ideal results are. I would like to add quite a bit to my forehead to make it more vertical instead of so severely slanted and I was wondering if I am desiring something beyond the limits that are currently set? I gave a picture of myself from the side with wet hair to give an accurate shape of my skull as a whole, especially the slanting forehead/top of head, and then another picture of what I am thinking I would like my forehead to look like. I look at pictures of myself (such as this one) and worry if it is only a small amount that can actually be added onto one’s skull, and if I am drastically unrealistic in my hopes, what are the limiting factors? Some of the ones I read about (like the amount the skin will stretch on one’s head) seem like the major one.
A: What you are seeking is a commonly performed aesthetic craniofacial procedure, forehead augmentation. This is done for a variety of forehead shape concerns, one of which is to change a sloping backward slanting forehead to a more vertical one. While the limiting factor is how much the scalp and forehead skin can stretch, the result you are desiring to achieve is largely very realistic and within the ability of the scalp to accommodate a greater volume and convexity underneath it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had eyebrow hair transplants 12 days ago. Anyway, it seems like the transplanted hairs have been falling out these past few days. There wasn’t much crusting or scabbing, and I have not noticed any blood on my eyebrows. I’ve spoken with my surgeon who has told me that it’s normal for the transplanted hairs to fall out. But I’m still a little concerned, which is why I would like your opinion as to whether this shedding is normal? If so, why do these transplanted hairs fall out and not continue growing?
A: The basic concept of any hair transplantation procedure, including eyebrow hair transplants, is to do follicular (hair bulb) transfer and implantation. The hair shaft is merely a handle by which to do that. It provides a convenient means to move the hair follicle into a new site. The shock of the transplantation procedure causes the shedding of the dead hair shaft 10 to 14 days after the procedure and is both expected and normal. The transferred hair bulbs are intact under the skin and new hair will not be seen until grows out from the follicle. Given the rate of hair growth, it will take months to see new hair emerge and a full six months to have the desires hair length that you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a middle-aged man who have been considering elective surgery for a long time. Due to my temple hollowness, I have had injectables (Radiesse, Sculptra, fat) in the area for long time, but with very limited effect and minimum duration. I am looking now into a more permanent solution, like temporal implants. On the other hand, due to my “sad look” a lateral brow lift has been offered to me several times, however, do you think that correcting the temples could fill up the area around the orbital contour or a lateral brow lift could still be needed? If so can both procedures be done together? My separate question to you is to whether a facelift could be performed at the same time as the one or the two procedures discussed above. Thank you in advance for your reply.
A: Temporal implants would be the only effective treatment option with your type of temporal hollowing. Your thin facial tissues have little fat and this explains why any type of injectable filler, including fat, can persist. Subfascial temporal implants will provide a permanent result by muscle augmentation. Temporal implants will not lift up the tail of your brows, n matter the size. That will require a temporal browlift, best done in men through a transpalpebral approach using an endotine fixation device. A facelift can certainly be done at the same time with careful placement of the incisions around the ears.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of cheek implant I think. I am not sure whether I have weak cheekbones or whether they are average or it is really a lack of fat or a lack of orbital rim development that gives me those lines under my eyes near the cheekbone. (Not tear trough) I have gotten comments on having a sunken/droopy “eyes” look when I’m cutting body fat and I’d prefer to have a much more healthy looking eye area when I’m at a lean fat %, just not too feminine either. I just wasn’t sure if that was primarily due to the cheekbone, orbital rims, or an odd lack of fat storage in that area of the face. So if am just to augment my orbital rims (lateral, inferior) and perhaps a bit of the anterior cheek (not too feminine) don’t you think fat transfer is my best option rather than a cheek implant, since a cheek implant doesn’t really touch those areas?
A: Cheek implants are your best treatment option but not the way you currently think of them. You do have a ‘weak’ orbitomalar area which is the result of infraorbital rim and cheekbone deficiency/underdevelopment and a thin soft tissue cover. Fat injection grafting will not work to create any sustained desired augmentation as it will be absorbed completely in less than 4 to 6 weeks after placement. The only effective approach is a combined infraorbital rim-cheek implant, probably only about 4mms thick, which will completely and permanently augment this area. While this is ideal, it will require a custom fabrication (thin tissues have no tolerance for anything less than a perfect fit that feathers on all edges) and that it will require an eyelid (subciliary) incisions to place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a follow up question in regards to your response to the question about using calf implants to correct the affects of polio. Is it not possible to use some type of balloon to stretch the skin in order to increase the amount of area available to accommodate the implant (similar to what is done for breast implants when someone significantly increases their cup size)?
A: Your question regarding the use of tissue expansion for calf implants is a good one and has some merit. However there is one major problem with it.Tissue expansion works most effectively when it has something hard to push off against. This allows the effects of tissue expansion to go in one direction, outward to the skin which can be stretched. This is why it works so effectively for breast reconstruction (ribcage) and the scalp. (skull) In the calfs, what lies underneath the fascia (which is where calf implants are placed) is the soft gastrocnemius muscle. With a very tight overlying fascia (like a trampoline) and soft muscle underneath, the effects of tissue expansion would be displaced inward and would have little effect on stretching out the overlying skin. One could place the tissue expander above the fascia in the subcutaneous plane right under the skin with the objective of eventually placing the calf implants in that plane. It is associated with a higher rate of complications (infection, visible outline of the implant) but may be reasonable given few other calf implant options. Besides tissue expansion, one could also do a first-stage fat injection to help both stretch the skin and create a better vascular bed for the second stage implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a novel browlift reversal procedure and I suspect if anyone can do it you can. A few years ago I had a brow lift performed. I hated the result. I felt like it stretched out the skin over my forehead too tight, making the bone underneath more prominent. I know in a typical scenario you might recommend a forehead reduction or some sort of burring. I however had a unique idea. I notice that in a few cases you mention the use of screws to hold the skin to the bone. I notice that when I push my scalp foreword toward my face, my forehead skin returns to the place it used to be. I was praying and hoping that you might be able to use that screw mechanism or whatever it is to hold my scalp in the forward position, returning it to its original position and thereby avoiding the forehead reduction, which I am not willing to even consider. It would mean the world to me if this could be done. I am desperate and in emotional pain. If you could make this happen it would be a God-send.
A: What you are describing is pretty much how a browlift reversla procedure is done. The very fact that you can do adequate mobilization of the forehead downward by pushing on the scalp suggests that is a real possibility to reverse your browlift. The concept of resorbable screw or suture anchor fixation to hold the released forehead tissues down is just as valid as using it to hold a browlift up. The only question then is what incisional approach to use to do it. What type of incision was used to do your browlift, endoscopic (which I assume), pretrichial, or coronal??
Using your existing endoscopic incisions (which are either two or three), the entire forehead and brows as well as the scalp behind them can be released. Then the scalp is advanced forward (epicranial shift) and is secured forward (pushing the forehead and brows down) by two or three point resorbable screw fixation to the frontal bone. I would anticipate this approach to a browlift reversal to work quite well as it is just a form of hairline/scalp advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want t know how to improve my disappearing jawline. Beginning about five years ago, the lack of definition in my jawline started to become progressively worse. Attached you will find some pictures that show a couple of different views that are fairly current as well as one from about 5 years ago to show how the lack of definition is getting progressively more noticeable as I age although I have never had that squared jaw that I like. I am in my late 40s now. While I know I will need to address the skin sagging on my lower face, jowls developing and neck laxity at some point, I am not ready for the scars associated with a face/neck lift. My hope was that by giving my back jaw more definition with angular implants, it would pull some of the loose skin simply by the sheer nature of adding some bulk but more importantly give me some definition so that it doesn’t look like my face just blends into my neck.
A: I believe you are correct on both counts. First, you are definitely not physically (or mentally) ready for any form of a jowl/necklift. That would definitely be too premature at this point in your early aging process. That day will arrive but you are at least 5 to 7 years from the benefits of that facial rejuvenation surgery. Secondly jaw angle implants, particularly vertical lengthening ones, will pick up some of the loose skin in the back end of the jaw and create more of a break between the jawline and the neck and give you more of that squared jaw look that you like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know for sure I want a Brazilian butt lift I don’t know how the procedure works. Do you take the fat from the stomach as I sure have plenty to give?
A: In a Brazilian Butt Lift (BBL), the goal is to get the maximum amount of fat possible to do the transfer injection procedure. In most people, the important question is whether they have enough fat to justify undergoing the procedure and to meet their aesthetic buttock size goals. The greatest donor site for fat is the abdomen, waistline and flanks. This is where about 80% of available subcutaneous fat depot sites exist in just about anyone. This harvest site is also the side benefit of the BBL, a natural body contouring effect from the necessary harvest site. This body site reduction is also why many BBL results look as good as they do…not because the buttock size increase is that great but but because what lies around the buttocks has gotten smaller and more shapely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have done further research on cheek implants and have a few question on them.
1) I have spoken to a few men who hated their cheek implants because they said it made them look feminine and gave the face more of a heart shape. Is it true that flat cheekbones are masculine? if so, in what circumstances can cheek implants be beneficial for a man? What’s the trick for a man? Is it too match the cheek prominence to the brow and jaw and not go over?
2) I was hoping for a subtle change in the under/lateral eye area, just to provide a bit more strength and less of that droopy look. Would fat transfer be better for this than cheek implants in my face? I very much do not want any apple look to the cheeks or even a rounded appearance.
A: The aesthetics of the cheek area when it comes to cheek implants is different for men vs. women. The proper fullness in the cheek for females is more in the anterior submalar area which creates the ‘apple cheek’ look and more of a softer heart-shaped face. In men, however, the proper cheek fullness is higher and slightly more posterior with the goal being to create a more defined and stronger cheeks. There are differences, of course, between what some men and women want but submalar augmentation in a man can definitely feminize the face. Flat cheekbones, however, would not be viewed as masculinizing feature. What you are showing in your attached picture is a very small amount of cheek augmentation but at least it is in the right place for a man. Cheek implants are always superior to injectable fillers and fat because they offer a one-time permanent solution that produces a predictable result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in belly button reshaping and it seems like you have done this surgery. Since most doctors said they can not do anything I am not sure if it is the stitching that is the problem or under the stitching. I removed my gallbladder last year, since then it has not been the same. I had a beautiful innie and now I am somewhat outie and it has been emotionally upsetting for me. I do not want to have any noticeable scars after doing the procedure or to make matter worse. I just want to make sure it will look the same as before. Please let me know how is it done and where is the scar hidden. Thank you so much for your understanding and your time.
A: Most cases of belly button reshaping is done to change outies to innies. Outie belly buttons may occur naturally or as a result of a surgical procedure as in your case. Your gall bladder was most likely removed by a laparoscopic technique of which one port was done through the belly button. Given that an innie belly button is nothing more than skin tethered down to the abdominal wall fascia, the insertion of the laparoscope disrupted this funnel-shaped attachment and now the belly button skin is just floating so to speak. Thus your innie became a partial outie now. Your belly button can be repaired by reattaching it back down to the abdominal fascia through an incision inside the belly button. This rsults in no scar on the outside. This can be done under local or light IV sedation anesthesia. I have performed this procedure numerous times for exactly the problem you now have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reduction. I really want to shorten my jawline and chin as I think the lower half of my face is too long I have a picture of me and what I hope to achieve after surgery by using a Plastic Surgery Simulator. I have no bite issues and I ideally want 1.5 cm vertical reduction of height of my jawline and chin producing a more rounder and shorter face overall. Is 1.5cm possible? Thank you
A: Vertical chin and jawline reduction can be done but not at the amount of 1.5 cms or 15mms. There is a good reason why that can not be done…the location of the apex of the roots of the lower teeth and the inferior alveolar nerve which runs through the lower jawbone. At 1.5 cms reduction, the nerve and tooth roots would be injured. There is also the issue of what would happen to the soft tissue that is currently covering your existing height of your jawbone. With that much bone removal, there would be a resultant soft tissue sag even if that much bone reduction was possible.
One issue that is common in facial bone augmentation or reduction surgery is that patients way overestimate how much change in measurements they really need. If you actually took away that much bone vertically, you would have very little jaw left. And the amount of desired in the height of our lower face in the Plastic Surgery Simulator is no where close to 15mms. That would be closer to 5 to 8mms. This is also a safer amount to lessen the risk of any soft tissue sag afterwards. One way you can measure how much bone you can safely remove is to get a panorex x-ray (a common dental film) that lays out the entire mandible like a map so the tooth roots and internal nerve can be seen. Then the vertical bone distance can be measured and actually determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. I am a 37 year old transgender. I started transition about eight years ago. I still need to have my browbone shaved and lifted a little. I’m just scared of side effects like big scars in the hairline and permanent numbness. Is the scar hidden in the hair ? Please advise. And how long before I can get back to my normal activities?
A: When it comes to brow bone reduction, there are two basic incisional approaches to it. The incision could be placed either at the frontal hairline or back further in the scalp. There are advantages and disadvantages to either incisional approach depending upon other features of the brow, forehead and frontal hairline. If one is happy with their current brow position, has a low to average forehead height (brow to hairline distance) and has any type of frontal hairline density, then the coronal (way back in the hairline) incision can be used to avoid any risk of frontal hairline scarring. But there will be a longer scar across the scalp and a greater risk of some reduced scalp sensation permanently. The frontal hairline (pretrichial) incision can be used when the brows need to lifted, there is an average to long forehead length (usually greater than 6 to 6.5 cms) and one wants to either maintain their existing forehead length or advance or lower the frontal hairline to to shorten their forehead height. The pretrichial incisional length would be shorter than the coronal incision (because it it closer to the brow) and there is less risk of any significant scalp numbness.
The scars from either the coronal or pretrichial incision usually heal well as evidenced on my experience of very few scalp/hairline scar revision ever requested. Quite surprisingly, even though the frontal hairline incision is more ‘exposed’, it actually heals very well as hair eventually grows through it. As a result, many brow bone reduction particularly in the transgender patients, use a pretrichial incision. This is also useful as hairline advancements, brow lifts and upper forehead augmentations (to create greater forehead convexity) are often aesthetically advantageous and simultaneously done.
Recovery from brow bone reductions is very similar to that of an open brow lift. It is all about how much swelling one gets around the eyes and how long it takes to go away until looks socially acceptable. That is usually about ten days.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a mouth widening surgery procedure.I have a VERY small mouth. It is of equal width of my nose (my nose is thin). I have read your concerns about post surgery scarring with this procedure and I think that for me personally, the benefits tremendously outweigh the risks. But I guess that’s for you to decide. I just have a couple of questions though first. How prominent are the scars? And can they be removed through either permanent makeup or steroid injections? I read that you said this procedure is easy. Please contact me when you can because your one of the only surgeons who is qualified enough to perform this. Thanks!!
A: A mouth widening surgery procedure (opening commissuroplasty) is a limited procedure and not difficult to undergo given that the corners of the mouth are small in size. The fine line scars are placed at the junction of the skin and vermilion around the corners of the mouth. Should the scars heal unfavorably, they will not be effectively treated by steroid injections or makeup, they will require re-excision and closure. (surgical scar revision) You should not think of scars being ‘removed’, they can be reduced but never completely removed. You are correct in your assumption that one’s mouth width (corner to corner) should exceed the width of the lateral ala when vertical lines are dropped down past the mouth. By ideal proportion standards, the width of the mouth should be 1.618 that of the width of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had plastic surgery done nearly 4 years ago that has left me what I consider deformed. I don’t resemble myself and there were so many mistakes the doctor made to my face. I am deeply saddened and depressed over this not only because of the cost but that I’m left disfigured and violated. I had my nose done where the doctor inserted a silicone implant promising that he would be able to correct my slight deviation with it. That was not achieved and my nose appears even more deviated, my nose looks short, and my nostrils more visible. I have thin skin so I feel you can almost make out the implant when looking at me. I would very much like to correct the mentioned issues. Also he performed an extraoral jaw reduction on me that left me further disfigured. He overcorrected and now my face has the appearance of a horse. I would like to restore the lost volume and give my face back it’s natural contour. Not to mention the incisional scar is very unsightly. It’s almost two inches long and is hypertrophic and red. I would like to revise the scar to make it less noticeable. I also had a silicone chin implant placed but it does not fit my face. It’s too big and wide and I would just like it removed and possibly have fat grafting to that area instead. I would possibly like other areas to be fat grafted as well such as my nasolabial fold and the hollows of my eyes.
A: From a nose standpoint, if you had an initial nasal deviation overlaying silicone implant on a nose that is deviated will actually make the nasal deviation look worse not better. So your outcome is not a surprise since you have to lay the implant on the existing nasal base. With thin skin and implant encapsulation, implant visibility often appears years later. From a short nose and nostril visibility standpoint, I am not sure how an implant would have caused that per se with the exception of a high bridge and dorsal line may make the amount of tip projection/rotation perceptibly look shorter and more rotated. From a secondary rhinoplasty correction standpoint, it appears that the implant would need to be removed and cartilage grafting done to augment and lengthen the nose with tip derogation as well as correction of the underlying nasal deviation which almost certainly has a septal deviation as a core root of the problem. The question is where the cartilage needs to be harvested from and that would depend on how much is needed. The debate is always whether it would be a combined septal/ear donor site or whether more is needed which requires rib cartilage. I would need to see some side view pictures to have a better idea in that regard.
From your prior jaw reduction procedure, I am assuming that the incisions and now red scars are at the back of the jaw behind the angles. (a side view picture would show that better) When you say you have lost volume and has changed you facial appearance (I don’t know if I would go so far as calling it horse-like), that likely implies that it looks too long because of the lost jaw angle volume and a steeper mandibular plane angle. (high in back and steeply slopes downward towards the chin) Restoring lost volume from prior jaw reduction in my experience is done by adding a jawline implant closer to the lost angle area to add some vertical length and a little bit of width.
Revisions of the jaw angle reduction scars can certainly be done and would likely result in a better outcome since they would not have the original traction. (pulling and stretching the skin to cut the bone) The interesting question about your scars is whether that access should be used for the placement of the implants since you have them already. That would make your recovery much easier than from gong inside the mouth. Whether the implants can be used forms standard stock sizes or should be custom made from a 3D CT scan is another issue to debate.
One of the may problems with chin implants done in women is that they are are often too wide as extended anatomic styles are often used. The question here is whether it should be replaced with a smaller central button style chin implant (which is far more appropriate for female faces) or replace with a fat graft with its unknown survival rate.
Lastly, fat grafting can be done for the nasolabial folds and eye hollows with the only real issue bend their survival is the risk of some unevenness or lumpiness in the eye hollow area due to the thin skin. This can usually be minimized by using a micronized fat grafting technique where the fat particles are made very small before injecting.
I hope these comments are helpful and if you can send some side view pictures that would be useful for further analysis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel that I have a slightly vertically long chin and a prominent jawline. My chin lengthens when I smile. From my profile however, my chin does not seem to have much projection and is slightly receding. A year ago I had a jawline and chin contour but I feel my results are minimal at best. I am consulting with you because I am looking for an expert opinion and what realistically can be done.
A: Often in chins that are retrusive, they are also vertically long because of the backward rotation of the entire mandible. (jaw) This would account for your chin lengthening when you smile but yet it looking too short in profile. I don’t know what type of chin and jawline contouring you had done but I would think your issue is improveable by a ‘redistribution’ issue as opposed to a completely reduction approach. (taking away bone with this nine shape would likely produce no substantial change in its appearance) It would seem that if your chin bone is brought forward and vertically shortened at the same time (angled sliding genioplasty) that would be the correct bony reshaping needed to address what the problem really is. I would envision no more than a 5mm chin advancement but a 5mm vertical shortening as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like I have a good bone structure but my jawline and lower face shape is hidden by excess fat. Will a buccal lipectomy get rid of the fat above my jawline and chin or would it get rid of the fat below the hollows of my cheek bones? I ask this because I know this procedure can create a hollowed skeletal/meth-head look and having very high cheekbones, I know I may be prone to this effect. I am 20 years old.. Though this procedure is generally for older people, do you think it would benefit me by outlining the contours of my lower face? I would like an estimate and maybe an opinion on the procedure if you can spare one. Thank you for your time 🙂
A: When it comes to a buccal lipectomy, it is important that one distinguish what it can and can not do. It can reduce some fullness right below the cheekbone which you can locate by placing your thumb on the underside of the cheekbone. As you can see by doing this, that will not affect any fullness below it near the mouth or the jawline. This is an area that I commonly treat with small cannula liposuction to reduce the fullness in this area. This procedure has no risk of ‘overskeletonizing’ the face as it is subcutaneous fat removal and not one large lump or ball of fat like that of the buccal fat. (actually if done properly and in a subtotal fashion a buccal lipectomy will not make the face too hollow)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking an ‘enhanced’ cheek dimple surgery. I already have one existing dimple on my right cheek. Can cheek dimple surgery enhance it and make it more prominent?
A: An existing cheek dimple already has the anatomic features that make it visible, an underlying defect in the buccinator muscle and a tethering of the skin down towards it. To enhance an existing cheek dimple (make it deeper and more pronounced) it is just a matter of removing some tissue between the dimple skin and the underlying muscle and placing a percutaneous suture to bring the skin further in to make it more deeper or more indented. This is a procedure that can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
