Your Questions

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

Q: Dr. Eppley, I am interested on finding out if a browlift I had done can be reversed or a brow lower ing procedure be done. About one year ago I had an aggressive endoscopic browlift done in which afterwards has  lifted my eyebrows way too high. I only had a minor brow sagging problem beforehand and was borderline for the procedure anyway. My surgeon told me they would eventually drop but have not done so and if they have it is clearly not enough. I look like the proverbial ‘deer in the headlights’ look compared to what I looked like before surgery. Can this overdone browlift be fixed in your experience?

A: Excessive brow elevation from an from an overdone browlift can be treated by observation for 3 to 6 months or a brow lowering procedure. Most overlifted brows will usually relax to an acceptable level. But if not, a brow lowering procedure can be done with a subgaleal dissection release combined with an intraoperative tissue expansion manuever. Using a small tissue expander placed in the mid-forehead, it is inflated to its maximum volume to aid with the subgaleal release. Done together, a browlift can be reversed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am about two months after double jaw surgery and sliding genioplasty to correct an open bite and weak chin. Everything is healing nicely, however since day one of my genioplasty, I have noticed that when I raise my lower lip or close my mouth, there is a “shelf” that forms from the mentalis muscle pushing up. It looks like a very deep labiomental fold, however it protrudes enough for me to be able to literally grab onto the muscle that is sticking out. This has been causing me to be tremendously depressed to the point where I’ve gone back to my surgeon and requested a revearsal of the genioplasty. I’ve been hearing about ptosis problems associated with chin augmentations, however mine seems to be the opposite. It looks fine with my mouth is open, however when closed, the muscle seems to be contracted too much and pushing out of my face. All of the doctors I’ve seen at my surgeon’s office seem to think that it will resolve with time, and that the incisions need to mature before the muscles can fully relax. However, it hasn’t shown any improvement. I was told if it doesn’t resolve by April, then it can be addressed, although I hate to wait that long. What I want to know is, what exactly is causing this, what is it, and by which method can it be fixed?

A: In a sliding genioplasty, the chin bone is brought forward and brings with it all of the attached soft tissue. Depending upon the angle of the bone cut of the genioplasty, the amount of bony advancement, the shape of the chin soft tissue pad before surgery, and how the mentalis muscle was sewn back will all influence how the chin soft tissue pad now looks and moves. What you are describing and demonstrating in your picture is a dynamic muscular deformity of the chin pad. (a roll becomes present when smiling, OK at rest) What I would do is first have some Botox injections done into this chin roll to determine if this is aesthetically helpful. If it improves with Botox then it becomes a later question of a mentalis muscle release and repositioning. (this also buys you some time without having the chin pad deformity as well ) If it does not improve with Botox injections then the only improvement is going to come from undoing the genioplasty to some degree. The interesting question in this regards is how much did the chin bone move forward and as it vertically shortened at the same time. In larger sliding genioplasty movements, the chin bone may come forward but may also get vertically shorter. This may cause some soft tissue bunching when one smiles as there is now an ‘excess’ of tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial liposuction.  I am slim but hate my chubby cheeks. Whatever I do they don’t go away. I tried buccal fat removal with little luck. Problem is the round bit of fat in malar pads which always goes very high on my apples of my cheeks when I smile. Can the cheek malar pads be removed completely? I want like male models so it looks like no fat at all on cheeks and so When smile it is just skin that raises up instead of the fat malar pad. I dont need malar lift, I just want it to be gotten rid of for good. Can it be completely removed and sucked out even if this may leave some sagginess of the skin. After that maybe I can have midfacelift if needed but I really want this malar pad gone. It is not buccal fat that I want gone, it is malar pad which rests on top of cheekbone. I don’t want a malar lift to redistribute fat on to higher position, just complete removal. Is it possible?

A: I understand perfectly as to what you are referring to and it is no surprise that a buccal lipectomy would have no effect. The buccal fat pad is in a lower anatomic location. The tissues that you are referring to are over the malar region but to describe them as the malar ‘fat pad’ is not anatomically accurate for what you are trying to achieve. The malar ‘fat pad’ is not like the buccal fat pad, it is not an isolated and thus easily extractable type of fat. Rather it is fat mixed in with other tissues giving it a more fibrofatty quality to it. Thus it is not amenable to excision (like the buccal fat pad) and is more resistant to small cannula or microliposuction. This does not mean it can not be treated, it is just a question of how effective it would be and that disrupting these tissues will cause it to sag as the suspensory ligaments would be traumatized. But when it comes to complete removal of the malar fat pad fullness, I do not believe that is surgically possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need some skin care advice. I was using both Task Essential Serum Revitalisant 02, 02 Revitalizing Serum in the morning, Task Essential Treatment Regenateur 02,and  02 Regenerative Treatment at night. After my operation, switched to Cetaphil. Do you think Task Essential are the best products to use? And is Task Essential New Skin Exfoliant the best scrub to use on my face? Also is Task Essential Pure Mask Instant the best mask to use on my face? And what is the best sunblock to use for my skin? By-the-way, when I use Cetaphil Cream on my face, should I use a lot.  And should I use a lot on my nose and instead of rubbing it into my skin should I let sit sit on my nose overnight?

A: When it comes to skin care products, there are literally thousands of product options. In reality there is no one single product or product line that is the ‘best’ or is the best for anyone. Probably hundreds of these thousands of product options would be effective for most people. What is important about any facial skin care product line is that one finds it non-irritating and comfortable to one’s skin as the benefits of any topical skin treatment is based on regular and sustained use. In short, neither of the two products you have chose is better than the other. Use the one you like the best.

The same issue applies to sunblock. Most moisturizers today contain sunblock and as along as it is at least SPF 30 in strength that is all that matters.

Your goal with any skin care product application is to use the least that works. Using more does not make it more effective, that only allows you to go through more product faster.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am in need of breast implant replacements. I had breast augmentation in 1991 and it appears one of my implants must have ruptured and has deflated.  I need to explore my options.The original surgery was done by using implants with a silicone shell with outer saline fluid.

A: Your original breast implants by description were what was known as Becker implants. They were a double lumen ( 2 bags) implant with an inner bag that contained silicone and an outer bag that contained saline fluid that was filled at the time of surgery. The logic of that old style breast implant was that it helped control silicone gel ‘bleed’ which had a known effect of causing high rates of capsular contracture at the time. (breast implant hardening)  Those implants have not been manufactured for over 20 years although some few patients still exist with them in. Like  a completely saline-filled breast implants, rupture and partial deflation (remember there js still an inner bag that has intact silicone gel) was inevitable. Getting 23 years of service out of these breast implants means you have done well. This day was eventually coming and it now appears that it is here. The only real significant question with breast implant replacements is whether you want to go with a completely saline-filled or silicone gel type breast implant and whether you want a similar size in volume with these replacements.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal implants but I have a twist to my need. I am bald and can’t regrow hair so I keep my head shaved. In addition I had a direct browlift last year so there are healed incisions right above my eyebrows. My question is can these implants be placed by going through the brow incisions? I hate that I would need temporal scalp incisions which would be very visible in someone like me.

A: While temporal implants may be aesthetically beneficial for you the question is how to get them in there in a ‘scarless’ manner in someone who shaves their head. This is a unique male question and not one that is seen in females. As you have read, the approach for temporal implants is from a 3 to 4cm incision just above the ear. While that approach makes it very easy and simple to do, the concept of a fine line scar in shaven scalp skin  does give me pause. Your question of whether a temporal implant can be placed through a direct brow lift incision is an interesting one and the presence of a scar in that area poses a unique ‘opportunity’. The eyebrow incision for temporal implants is one I have never done and I doubt if it has ever been done anywhere in the world to date. By its proximity your eyebrow scars provide direct access to the area of temporal hollowing but the attachment of the temporal fascia to the lateral orbital bone is quite stout and would have to be released to gain entrance to the subfascial temporal plane. (having done a lot of craniofacial surgery I am very familiar with doing surgery in this area) The simple answer to your question is that it is theoretically possible and if one was doing some adjustment of your direct brow lift anyway there is no reason not to try. If it becomes too difficult to do, one can always then switch to doing fat injection into the muscle and on top of the fascia to create a temporal augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am interested in some form of forehead reshaping.  I have two hard-like horns or lumps on my forehead. They have been there since I was a teenager. Now that I am in my early twenties it bothers me greatly. They feel like really hard like bones. They really affect me and bring my self esteem down. I’ve been to my family doctor and I was told it was really nothing. I am hoping you can help me. I have attached pictures from different angles for your assessment.

A: One of the most minor forms of forehead reshaping is reduction of prominent bulges. Your pictures show a very classic example of them and how protuberant they can be. Thank you for sending your pictures. They are the type of forehead bulges/osteomas/horns that I have seen many times. They are common excess growths of the forehead bone and are almost always on both sides.They are benign and normal but obviously not aesthetically desireable. They can be burred down to make for a more smooth confluent forehead contour. Depending upon the shape of the rest of your forehead and how much they can be burred down, it is sometimes also helpful to build up with bone cement around the area to get a really smooth forehead shape. That shaping consideration aside, the only other issue to consider is one of surgical access. You have to have an incision somewhere to gain access and this would be back in the scalp. Thus one has to accept a very fine line scalp incision to do it. Fortunately even in men with thinner or thinning hair cover, the scalp incision heals well with very minimal scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking about having some overseas plastic surgery (breast augmentation and liposuction) done in Costa Rica. I currently live in Indiana but I can get it done over there for about half the cost of here. Do you think this is safe or a bad idea? The idea of having the surgery in a warm climate seems appealing, particularly when it comes to getting a new shapely body!

A: While the appeal of low cost or inexpensive plastic surgery certainly has its appeal, as evidenced by a booming medical tourism industry, it is important to also look at its downsides. Like any aspect of plastic surgery, from the procedure to the plastic surgeon to the facility, one has to calculate the risks as best they can.

While complications of all sorts certainly occur amongst plastic surgery procedures in the U.S. (fortunately most are aesthetic in nature) there are less safeguards when traveling overseas particularly to third world countries. One major issue that most patients don’t think about it is the sterility of the procedure and how medical equipment and supplies are handled. (and even reused) The lack of following adequate sterile surgery protocols and the re-use of medical supplies is one way to keep down costs but place patients at increased infection risks. Just like you might not drink bottled water in some countries, would you really trust something much more important like actually entering your body?

You are also hedging your bet that you will have a complication-free surgical outcome, whether it be a medical or aesthetic problem. In lands that are not teeming with lawyers and medico-legal oversight, your far away surgeon may have little regard for a patient once they leave the operating room…and certainly has no obligation once you return home. (other than what you might say on the internet) When the long-term outcome  appears to have little real consequence, what level of detail and attentiveness might your far away surgeon hold themselves to?

While this discussion may seem negative about medical tourism and there are undoubtably many good experiences and results, it is really to provide you with the flip side of the coin of lower surgical prices. Like most things in life, it is all about how you want to hedge your bet on your plastic surgery outcome and what would happen if all does not go well. The most recent report of mycobacterial infections from plastic surgery done in the Dominican Republic by the CDC illustrates that point.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in extremely large breast augmentation. How big of breast implants do you do? I currently have 1200cc saline implants, under the muscle. Recent surgery done late last year. I realize I’m not done healing and I can’t have a revision for some months down the road, but I would like to at least double in size. I’m shooting for the 4000cc range one day. I’ve heard some surgeons say these sizes are not possible. My first surgery I’m not happy with, I was hoping for more roundness and projection. Please let me know if this sounds like a surgery you think you are capable of. Thank you

A: When it comes to extremely large breast augmentation, it is not a question of capability but implant possibility. Extremely large breast implants require that they be saline and overfilled. The largest U.S. manufactured FDA-approved saline breast implant is 800cc of which the manufacturer recommends a maximum fill of roughly 1000ccs. But they can be safely filled to more than that as your case illustrates. How far beyond that one can safely go has never been studied and is not scientifically known.The physical characteristics of the implant when filling to saline volumes of 2000cc or more with base sizes of 800ccs involves issues of rupture potential and extreme hardness of the implants. When it comes to filling to 3000cc or 4000ccs that is not going to be possible with any FDA approved saline breast implant.

While larger base size saline breast implants exist outside of the U.S., the vast majority of plastic surgeons are not going to risk their medical license by illegally importing in non-FDA approved foreign medical devices.

It is clear in looking at your pictures that you have a lot of breast skin and it has the capability of even great volumes than 1200ccs. And as a general rule, you do have to increase your volume by at least 50% to see an appreciable size difference. But a greater overfill than that is probably not going to be tolerated by the implant shell without a significant risk of rupture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got a scar on my wrist due to a traumatic injury. It has left a mark in the direction of the injury where the surrounding area seems to be darker than the other parts of the skin, upon bending my wrist, a white sheen is observed with mild indentation observable. The darker surrounding I mentioned seem to be coming from the missing skin and dent in rather than hyper-pigmentation? Is there any treatment available for this? The scar is still quite visible right now at the 10th week. I have been hearing that one should wait for 3 to 6 months before undergoing any treatment so as to see how the scar heals up first? Is that true? What is the downtime involved per treatment and how many treatments would be required for my case based on your experience? I am a little skeptical as to how the outcome would be like since the laser results I see are usually from tattoo removals and trauma scars on the face.

A: When it comes to scar revision, regardless of whatever the treatment may be, it is important to identify what are the physical aspects that make the scar noticeable. And then based on those physical characteristics answer the question of whether more time (scar maturation) will be helpful to improve its appearance. The issues of hyperpigmentation and wound contracture at less than three months after the injury are issues in which time may well improve them. Whether they will improve to the point to your satisfaction remains to be seen. The other compelling reason to allow for further wound maturation is that there are no good treatments for these types of scar problems. Much ‘magic’ is ascribed to the use of lasers in scars but much of that for common type scars is over rated in terms of effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in female chin augmentation but have some concerns. Many before and after pictures that I have seen show chins that look too strong to me with too much horizontal advancement. I am a 27 year old female and want to do something to improve my weak chin/jawline. Take a look at my attached profile picture and tell me what you think.

A: Female chin augmentation is different both aesthetically and in implant designs that what is done on most men. This side view picture makes it infinitely clear as to your chin concerns. In a female chin that is deficient, the critical question is how much horizontal advancement is desired AND what happens to the width of the chin as it comes forward. In women the chin should become more narrow or triangular as it is advanced forward. This can be done by either a sliding genioplasty or central button chin implant style. I will need to do some computer imaging to see how much chin change you are looking for. In women, less is always more when it comes to chin augmentation in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know if a paranasal or premaxillary augmentation would help add volume to the area around my nose. Its sunken in and people always tell me I look sad when I’m not sad. Do you do this procedure using an implant? Or do you use rib cartilage?

A: The Asian midface is a common area in which I perform paranasal and premaxillary augmentation. With a genetic predisposition to a more flat facial profile (or even a concave profile), ‘pulling’ the base of the nose out by bony augmentation will certainly add volume to the base of your nose for more midface projection. The usual amount of augmentation is in the range of 6 to 8mms. I have used both implants and rib cartilage for paranasal augmentation depending on the patient’s request. The vast majority of patients opt for implants because it does not require a donor site. The few patients in which I have used rib grafts for midface augmentation is when they were also having rib taken for a rib graft rhinoplasty so they were having a donor site anyway and the paranasal augmentation was a coincidental byproduct of the other procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m hoping you can fix my ear. I have hardened cartilage on my left ear that has caused my helix to flatten. I am hoping you can shave/remove the hardened cartilage and return my ear to it’s original shape.

A: I am going to assume that the hardened cartilage in your left ear is from some form of trauma. Perichondrial sheering and hematomas can cause cartilage to grow and thicken the natural ear cartilage resulting in loss of the normally concave portions of the ear and/or making the convex areas even bigger. This is classically seen in the ‘cauliflower ear’ with varying presentations from smaller areas like yours to those that can even involve the entire ear cartilage.

You are correct is assuming that the hardened or thickened cartilage must be thinned down so that the helix fold can be recreated in an ear reconstruction procedure. This is done by raising the skin over the thickened area and shaving down the cartilage with a scalpel or dermal punches. Whether skin flaps must be raised on both sides of the ear to create adequate cartilage reduction can not be determined by a picture alone. The real key to this surgery is to ensure that a recurrent hematoma or fluid collection does not occur after surgery beneath the raised skin flaps as that will cause the same problem to recur. This is done by a combination of through and through resorbable sutures with a xeroform bolster dressing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had Juvederm injectable filler placed into my lips  three days ago. Right after I had a redness that kind of spread to my nose and cheek as well as some lip bruising. The bruising is getting better, however, the redness is still there. Did the injector hit a vein or artery??? Is my tissue dying?

A: When it comes to any injectable filler, there are a variety of  minor and often self-limiting complications that can occur with them. Bruising and swelling are by far the most common and are self-solving. The most uncommon complication is a mild or sometimes significant inflammatory reaction to the filler material which is quoted from numerous large clinical studies as being in the range of 1% of those injected with the hyaluronic acid-based fillers. (which is what Juvederm is) Other filler types have a higher incidence of these issues, hence the popularity of fillers like Juvederm. An inflammatory reaction is usually seen as erythema (redness) around the lips associated with swelling. It occurs quickly after the injection and the lips can become quite large, often impressively so. Redness without swelling is possible but would be an uncommon presentation. Also redness would not necessarily be expected to progress up into the nose and cheek and would be localized to the injection site.

Since I did not inject you or have seen what you look like, your description alone does not present a clear picture as to exactly what is the cause of this redness. What I am fairly certain of is, however, is that your tissues are not dying. (undergoing necrosis)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting jaw and cheek implants, but I am waiting until there is a more natural choice. I want implants that integrate with the bone so I won’t have to worry about shifting. I’ve read online that some doctors have been able to 3D print bones that integrate with the bone. How long until this is applied to cosmetic surgery?

A: If your primary concern about cheek and jaw implants is that they will shift, there is a far simpler technique available today that ensures that will not happen…known as screw fixation. Securing the implant to the bone with small titanium screws ensures that it will never move and is a technique of implant fixation that I do to just about every facial implant that I place. I have used that implant technique for over twenty years and I have yet to see a facial implant that has yet moved from where I placed it.

When it comes to 3D printing of any human tissue, this topic has been in the news of late and is a technology that is quite early in its development. All the recent press releases demonstrate that it can technically be done. But that is far cry from being able to do it in humans for real surgery. I do believe that one day such technology will be available for surgical use but, at a minimum, it will be 10 to 15 years due to FDA regulations and the clinical approval process which is involved in getting it through those hurdles. This does not take into account the economics of the process in which a company has to invest millions (or tens of millions) to get it through that regulatory process. And a company will only do that if the market in which they are developing their product for justifies that expense. The facial implant market would not be considered such a market by today’s standards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking an Asian rhinoplasty. I want the maximal amount of nasal tip projection and thinning that can be achieved. What can be done to give the nose these tip changes and want can I realistically expect if I do them?

A: In every single case of an Asian rhinoplasty that I have ever done, improved tip projection and shape is always a primary aesthetic goal. There is a limit, however, as to how much nasal tip definition can be achieved based on the thickness of one’s skin. The most nasal tip definition can only be achieved by the combination of a columellar strut, lower alar cartilage dome narrowing and stacked shield grafts on top of it. (if using rib it would be an L-shaped construct)  In every case of an  Asian rhinoplasty that I have done this i always the objective and the maximum tip lengthening procedures are done to achieve it. The only caveat I would add is that the amount of tip projection created can not cause some much pressure on the tip skin that it blanches it on closure. This will set up the  potential tip skin necrosis.

Whether this approach can achieve what you are expecting is a bit of an unknown as you can not simply make ay Asian nose as long or as thin as some patients would like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to know if I can have a breast lift with implants in place. I had breast augmentation before I had children at 26 years old. Seven years later after two children my breasts have gotten so heavy and saggy. I saw one plastic surgeon who said he could just do a breast lift using my current implants. My concern is having a lift then having to go back in in a few years to have saline implants replaced when they eventually deflate. Would love to get good result with breasts that are lifted with more upper pole fullness using my current implants.

A: As long as the implants are in good position, one can always have a breast lift on top of them. No one can predict how long your current saline implants will function before they fail. It could be next month or ten years from now. To get the best value from your current implants, I would recommend having the breast lift and leaving the implants alone. They are not that old and you should get more than a few years of use out of them. You can always replace them with silicone implants when they fail as such a replacement surgery is very easy with next to no real recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, thank you for the great fat grafting done to my cheeks a few weeks ago. It has helped a lot and I know that it is too early to tell how much fat will survve. But should a significant or at least enough fat go way that I want more at the three month time after the surgery, would you be able to go in and get more fat to put into that cheek?  I was looking at some publications by Coleman and it appears that it is OK to inject more into the face after a three month waiting period.  Also, is it true that you can extract a lot of fat and then freeze it for use in future treatments?  What does the literature say about this type of procedure?

A: Secondary fat grafting can be done anytime after the initial procedure. The reason that the three month time period is given is so that one has enough time to fully appreciate how much fat has taken. Three months is the generally accepted time period to see the balance between what fat has died and been absorbed and how much has survived…thus making the final achieved contour change visible. Harvested fat can be stored in a frozen state for future use. Despite its appeal, however, the medical literature indicates that the thawed and re-injected fat quickly undergoes complete resorption. While not completely understood, the freezing and thawing process apparently is very detrimental to fat cells. (adipocytes)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am debating on a sliding genioplasty vs silicone implant for chin augmentation.. I know that up to 10mms in vertical length can be achieved by a genioplasty, as well as width changes through hydroxyapatite blocks. I would like to get your personal opinion on this. For a male, what would be a normal range of chin length from lowest part of the bottom lip to the end of the chin? What length would the chin need to be for a male in order to warrant a lengthening genioplasty or to declare it unnecessary? I want to add as much size to my face as possible, length and width wise.

A: For chin augmentation, both a sliding genioplasty and an implant can be used to create vertical length for a more profound or dominant chin. However, there is no standard or normal range for how vertically long one’s chin should be. It is more of a ratio to the other vertical facial thirds and how dominant one prefers their lower third of the face. As a general rule in my experience, few patients need the vertical length of the chin increased by as much as 10mm. That would be too long for even many men, particularly when other dimensions of the chin are being added as well.

While a sliding genioplasty is traditionally perceived as being the only method to vertically lengthen the chin, custom designed implants can also be used today.  However they may not do it equally well. Because of the limits of the bone cuts of a sliding genioplasty, significant vertical lengthening may look ‘unusual‘ as only the chin of the jawline drops down. In contrast,  custom designed implant can vertically lengthen a larger portion or the entire jawline for a more natural blending of the vertical lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty a few months and this dent has appeared between my lip and chin that was not there before the surgery. Why has this dent occured and can it be fixed. While I like my new chin position, I do not like this dent and want it fixed if possible.

A: A sliding genioplasty moves the chin bone forward but does not change what lies above it. That dent is the labiomental fold/sulcus which is the fixed attachment of the superior mentalis muscle to the bone. It may have become more prominent after surgery due to the chin advancement and/or scar tissue or a tightly restored mental is muscle attachment. I have seen this numerous times after chin advancement procedures particularly sliding genioplasties. It can be improved/fixed by either an intraoral release alone or combined with a dermal-fat graft after the release to prevent it from becoming re-attached.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, I am looking into hairline lowering, jaw reduction with male liposuction (chin too long), brow reduction (I believe I will have to have my brow cut off and reshaped. Also, I have heard of a procedure called the FROST procedure for hairline lowering without a tissue expander. Do you perform this procedure? I have a high forehead and want to make sure it is right.

A: Hairline lowering in men is unique because of the important and unknown stability of the male frontal hairline. The patients has to be selected carefully based on their hairline pattern, density, age and genetics. Having done numerous male procedures that involve an incision along the frontal hairline (hairline lowering, pretrichial brow lifts, brow bone reductions), I have always been impressed with how well the scar usually does despite an always concern about it. Interestingly, recent published research has shown that the hairline incision (in women) seems to preserve hairline stability. (whether the same is true in men is speculative but not necessarily proven) The amount that the hairline can be moved forward depends on the natural stretch of one’s scalp and the technique used to do it. While there is no question a tissue expander always ensures the maximum amount of hairline advancement, most patients do not want that two-step process. (particularly men) There is nothing new or unique about the FROST procedure for hairline lowering. It is a good acronym for the technique but is an approach that I commonly use in men or women. Most surgeons think of hairline lowering a raising up a portion of the top of the scalp to bring it forward. This more limited approach to hairline lowering will usually not get more than about 1 cm of movement at best. But if one raises the entire scalp (behind the hairline incision) in a subgaleal plane the whole to the bottom of the back of the head, scores the galea for further release and then secure its anterior edge to the desired position on the frontal bone with transosseous sutures, advancements of 3 to 5 cms are possible. (this is what is done in the so called FROST procedure) It is just a more aggressive form of scalp mobilization that many surgeons may not feel comfortable doing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ll be getting eyebrow transplants done next Monday. I’ve also been looking at getting some fillers to augment my radix (and possibly glabella). Anyway, my surgeon has advised me that it should be fine to get fillers shortly after the transplants (he suggested doing it next Friday) as they won’t be in the same area as the transplants. Just wondering though, will getting fillers so shortly after the eyebrow transplants have any adverse effects on hair growth? Thank you for taking the time to answer me.

A: In short, there is no correlation between having eyebrow transplants and injectable fillers. Even if the fillers were being injected right under the brow at the same time as having hair transplants, it would not affect the take of the hair transplants or how well they would subsequently grow. Given that the injectable fillers would be placed in the radix of the nose, away from the hair transplants, makes it even ‘safer’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a forehead osteoma removal. I have a bump inthe dead center of my forehead that I would like removed. It sticks out like aore thumb and is very visible and bothersome to me. I have attaches several pictures to show you where it is.

A: It is hard to say based on this picture whether your forehead bump is an osteoma or a natural frontal bone contour. That distinction is critically important as it affects the surgical technique to remove it. An osteoma is a bone growth that develops over time and looks very much like a flattened mushroom sitting on top of the bone. Because of its shape,it can be fairly easily removed by an osteotome (chisel) from a remote incision in the scalp. (endoscopic technique) In essence, it is just swiftly chiseled off of the bone. Conversely, a forehead bump that is just a natural part of the frontal bone has to be taken down by a handpiece and burr. This is much more technically challenging from an equipment standpoint when trying to that with an endoscopic scalp approach. (particularly given that it is way down in the center of his forehead.

The history of the bump goes a long way in defining what it may be. A natural frontal bone contour/bump will have been there since he was born or very young. An osteoma often appears later in life often after a traumatic event.

By feel, they also can have a different feel to them. Some osteomas almost feel like there is a ‘lip’ at the edge. While a natural born bump will feel smooth with no palpable edge or lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial feminization surgery. I specifically want: 1. lower forehead and brow ridge bone contouring, 2. forehead and eyebrow lift, 3. hairline restoration by scalp advancement and hair transplantation, 4. upper forehead bone augmentation, 5. frown line and crow’s feet surgical correction, 6. feminizing rhinoplasty, 7. cheek (malar or submalar) augmentation, 8. lip lifting, 9. chin contouring (reduction) & sliding genioplasty or chin augmentation by implant 10. jaw contouring (reduction). I also would like to know if possible can i have all these procedures done at the same time ?

A: All of the procedures you have listed are very common and often part of an overall facial feminization surgery (FFS) approach. When it comes to FFS surgery, most of them can be done all at the same time although some work against the others and are best deferred for a second surgery if needed.

Brow bone reduction/reshaping, upper forehead augmentation and scalp (hairline) advancement can all be combined and would need to be due to the same incision used for all of them. At the same time, a rhinoplasty, cheek implants and chin/jawline recontouring can be done.

There is no specific surgery for crow’s feet or frown lines. When doing an open rhinoplasty, a lip lift can not be done at the same time due to blood supply concerns of the intervening columellar skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just wanted a consult to see if a tummy tuck or laser skin tightening would be an option for me. I had a child almost two years ago and lost over 60lbs.

A: The decision between a tummy tuck and another abdominal contouring option is often debated. However, you have said two things that helped define your tummy options, even without seeing pictures of it. (although that would also be helpful) The combination of having a child and losing over 60lbs had made the use of laser skin tightening an impossibility. Even at best, laser skin tightening may be able to tighten about 1 cm. (1/2 inch of skin) I suspect that the amount of loose abdominal skin that you have exceeds that by a considerable amount. Being between stretched by pregnancy and then losing that amount of weight, the elasticity of skin has been broken and its ability to tighten removed. A tummy tuck is undoubtably what you will really need to get the improvement in abdominal tightening that you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Smartlipo laser liposuction procedure. I have a fatty tumor behind my arm and would like to remove it with the least invasive procedure. I also have fatty tumors in my legs which would love for them to be gone also.

A: Smartlipo or laser liposuction is one possible treatment approach for smaller lipomas. While all of these lipomas could be simply removed by excision, I could understand why you would not want the fine line scars. What is important to understand is that treating them by Smartlipo/laser liposuction is not quite the same as removing traditional unwanted fat. Unwanted fat is soft non-encapsulated fat that extracts easily and thoroughly after being partially liquified by the laser energy by small cannula liposuction. In contrast, lipomas are well encapsulated ‘balls’ of fat that are really benign tumors. The laser energy may break them up into small pieces but it does not necessarily liquify them completely and thus they are not as easy to extract by liposuction. The point being is that the laser liposuction treatment method of lipomas is best viewed as a reduction method that may or may not result in them being completely removed.

Dr. Barry Eppley

Indianapolis, Indiana