Your Questions

Q: Dr. Eppley, I am interested in skull reshaping surgery for the back of my head. I have attached some pictures. Although they are a little fuzzy I think you can see the problem. The left is much flatter than the right. Let me know if it is possible to do what I want which is to fix the head shape so that it is more round and therefore more normal in the back on both sides (more on the left than the right.) I also have a few more questions to ask. First of all, are there any long term side effects of the surgery? (not the rare ones but common ones I should know about as I know there are risks with any surgery). Secondly will I need to keep coming back for surgeries in the future (for such things as touch-ups)? Will it affect my hair growth? These are questions I was unable to find out for myself. I hope I have not been too much much of a bother. I am really excited for this as you can see and I really, really appreciate your prompt and helpful responses. Thank you for everything.

A: As skull reshaping surgery goes, your back of the head problem is the most common skull problem that I treat. Flat back of the heads are common and rarely are they perfectly symmetrical. They are corrected by an onlay cranioplasty procedure, most commonly using PMMA as the augmentation material. The surgery is done through a limited 9 to 10 cm incision (no hair is shaved) placed closer to the back of the head through the material is applied and shaped. The only short-term complication (< 6 months) that I have ever seen is aesthetic in nature, how smooth is the applied material and does it give enough of the desired augmentation. If either is observed and bothersome, a touch up procedure may be done to smooth it out or add more material if possible. I have not seen any long-term complications. If one has a satisfactory result by three months after surgery to their own assessment, then no further procedure will ever be needed. Lastly, he procedure does not affect hair growth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about temple implants. What I want is to build width and length to my face through multiple procedures. (Not all done at the same time of course). These include jaw implants to add width and vertical length to the face, a chin implant which meets the jaw implant, and forehead widening from the temporal region up into the sides of the head, and possibly heightening. I believe the chin and jaw implants are relatively straightforward, but the forehead is a bit more complicated to me. Is the recovery period painful for skull reshaping and is there a significant loss of blood? One question I’d like to ask is how much width can be added to the forehead on each side? Is it possible to broaden the forehead up to 1cm on each side stretching from the cheekbone all the way up to the highest part of the head? As you can tell I really want to completely restructure my face to more large proportions and just add volume all over as it has bothering me greatly for some time now. I do not want to do anything with my features as I like my features, its the size of my structure that I really want to change.

A: When it comes to temple implants, there are two major factors to consider in your specific request. First, the amount of temporal and forehead augmentation is only limited by the ability of the scalp to close over it. Based on a lot of experience in these kind of surgeries I would say that a 1 cm increase on each side is very achieveable. Secondly, it will require custom designed temporal implants that would be made to start at the zygomatic arch and create a maximal 1 cm width increase at the point of maximal convexity as it blends into the forehead area. I have designed such temporal implants in the past so this amount of temporal volume addition I have done before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty but want to know how much it can change the shape of the chin? What is the maximum vertical height and horizontal projection I can receive?

A: The maximum chin changes that can be achieved with a sliding genioplasty is based on the thickness of the chin bone, particularly as it relates to increased horizontal projection. You do not want to move the osteotomized chin bone beyond contact with the superior fixed chin bone. In general, that puts the advancement in the 10 to 12mm range which based on your picture seem more than you would need. As for vertical lengthening, the amount that the osteotomy can be opened depends on whether the created gap would need to be grafted. (with an hydroxyapatite block)  For openings up to 5 or 6mm, no graft would be needed. But anything beyond that (8 to 10mms) would need to be grafted. Again, that distance seems greater than your picture would indicate that it is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in inverted nipple repair. However I don’t know anything about the procedure and how it is done. Can you help me with that information.

A: I believe you are inquiring about correction of inverted nipples. They are several types of inverted nipples based on the degree of fibrosis/tethering that is causing the inversion. The degree/type of nipple inversion cabe be determined by several factors including its presence since breast development or only developing after pregnancies/breast feeling and whether the nipple can be temporarily everted by gently squeezing it between one’s fingers or not. While all inverted nipple repairs are done by making an incision at the base of the nipple and the tether released, those inverted nipples with the greatest degree of firm inversion may require a small graft, usually fat, to fill the space that is caused by the nipple moving outward. Suturing the space beneath the nipple to hold it outward is a common technique but I have found that to be unreliable long-term at preventing relapse and recurrent nipple inversion. Thus the use of a fat or dermal graft can be very beneficial. In many cases an inverted nipple repair can be done under local anesthesia or conscious sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an endoscopic brow lift to help lift my upper eye lids. Although I had an upper blepharoplasty done over three years ago, that surgeon not only did not remove enough skin to eliminate the ‘hoods’ over my eyes, he did not take precise measurements before surgery (he ‘eyeballed’ the distance, no pun intended, as if he was about to saw a piece of 2 by 4 wood). As a result I ended up with very little to show for that surgery – other than insufficient skin removed – and the brow lift was intended to correct this. Unfortunately, all that I appear to gotten out of the brow lift is two incision lines in my forehead (thankfully hidden – for now – in my receding hairline) and a couple of bumps in my forehead (where the dissolvable endotine ‘screws’ were presumably fitted). My middle brow (over my eyes) was not lifted. My upper lids are just as ‘hooded’ as they were before this surgery, and I am now being told that what needs to be done next is a revision blepharoplasty – a procedure I had asked about having done before the brow lift. It looks like I may have paid for what may have only been a ‘temporal brow lift’ and not a true middle brow lift, and I still need the revision blepharoplasty that I perhaps ought to have had done instead of this endoscopic brow lift.

A: The endoscopic brow lift, and in the results obtained, are highly dependent on the location of the scalp incisions. Where the scalp incisions are above the brows will determine exactly where the direction of maximal brow lifting is done. Unless the scalp incisions are directly in line above the medial brow areas, this area will not be lifted. In addition, in men, the effects of any browlifting is more modest. Thus any residual upper eyelid skin will not be removed and should be dealt with at the same time as the brow lift. It sounds like your case illustrates all of these points.

Q: Dr. Eppley,  I had a subnasal lip lift a month ago and it clearly has been overdone. My upper lip, which now does show more teeth, looks like a snarl. My upper lip is too short. What I do not understand is how I could have only ended up with 12 mm of philtral length when I had 21 mm to start with? It sounds like 9 mm of upper lip skin was removed? Although that’s only 2 mm more than the maximum for females, it’s almost 4 mm (or double the maximum distance for females) that should be shortened for a male. Although we are only talking millimeters, that’s like a ‘moon shot’ missing it’s target by hundreds of thousands of miles! What can be done to fix an overdone lip lift?

A: A subnasal lip lift notoriously has 1 to 2 millimeters of ‘relapse’ so I would not rule out that some lengthening all occur despite how it feels. Given that it is just about a month after the procedure, I would start to stretch out the upper lip using your fingers and your tongue from the inside. You might be surprised what can happen by six months after surgery.

As for the techniques that plastic surgeons use to ‘mark’ their surgery, I can only speak for how I do it. It is important to mark out such surgeries beforehand using calipers and magnifying loupes to design the surgery. Just because it is marked out carefully does not always ensure a perfect result but without such precision in the plan the result will have no chance to be close to the desired goal. As the old motto goes ‘You Can Not Hit A Target You Do Not Have’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read you perform temporal artery ligations. I am considering this procedure since I have two very prominent arteries on both sides of my head that are very visible.

A: Temporal artery ligations can be done and doing them is actually not rare in my experience.. They usually require at least a two-point and sometimes a three-point ligation to make sure there is no unchecked flow into the ligated artery either through the main superficial artery trunk (anterograde) or from retrograde flow from the distal end of the vessel.  These require small incisions (4 to 5mms) in the temporal hairline and at some distal location in the forehead/temporal area. They are done under local anesthesia as a simple outpatient procedure. Since you have two prominent temporal arteries, which are likely just branches of the same vessel, I would need to see a picture of the prominent vessels to see where the ligations would need to be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get a corner of the mouth lift. I am a 43 year old Asian female with no fold. I have a neutral corner of mouth, but I just want to have a happier mouth when I’m not smiling.

A: The corner of the mouth lift is traditionally done for aging in which the corners of the mouth are turned down. By removing a triangle of skin from just above the mouth corners, the lateral commissure point is moved upward. While it does produce a small scar (usually about 7mms in length) that tails away from the corner of the mouth, it creates a very noticeable change in the location of the mouth corners.

In the neutral or non-downturned mouth corner, such a lift creates upturned mouth corners also known as a ‘lip curl’. Such a mouth shape has become popular in Korea and Japan as a sign of a beautiful mouth shape. While imparting an upturned mouth is the opposite of what is desired in the Caucasian aging mouth, this is a modern day use of an older plastic surgery procedure for a more contemporary application.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting Botox injections to treat my severe clenching and grinding. I have tried every dental approach from teeth adjustment to splints and none of them have really done anything. I am worried about the wear on my teeth which is starting to become noticeable. You seem to be the only doctor in Indianapolis that does these type of injections for this problem. I would like to know the average cost of one treatment and average time it relieves the forceful grinding of bruxism.

A: I have done Botox injections for bruxism (grinding, clenching) for well over a decade. In the right patient, it can be tremendously effective if administered properly. As a general guideline, most patients should have 20 units of Botox injected into each masseter muscle for a total of 40 units. This would be the minimum effective dose but a good starting point to see how effective Botox may be for the bruxism. If I inject the Botox it is $16/unit, if my nurse performs the injections then it is $10/unit. The effects of Botox take up to a week to see its effect as it works by depleting the available neurotransmitter acetylcholine, so what it stored up has to be used up before the muscle fibers stop firing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in liposuction or a tummy tuck, preferably liposuction though. I have had two pregnancies, seven years apart with the last one being five years ago. This has left me with loose skin and fat around my mid section. I am 38 years old and weigh 140 lbs and have a 34″ waistline measurement. I feel great, I just can’t get rid of the skin and fat around and under the naval area. I have had two abdominal surgeries in the past and skin hangs over the suprapubic scar. If I just have liposuction will I be left with flabby skin?

A: As a general rule, if one has significant loose skin on their abdomen before liposuction they will still be loose skin afterwards. While many forms of liposuction have been touted about their ability to tighten skin, the amount of skin tightening obtained is almost always far less than what patients desire. As I always tell patients, liposuction can tighten skin in the range of millimeters, however, patients are interested and need skin tightening in the range of centimeters most of the time. With loose skin around the belly button and overhanging a suprapubic scar, you would be better served by having a mini tummy tuck which would incorporate liposuction with it. Given that you already have a suprapubic scar you might as well take advantage and use the entire scar for a mini tummy tuck. It does not add that much more scar length and its ability to remove skin make it more than a worthwhile trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a reduction otoplasty. The height of my ears is too tall for my head/face.  I have talked to several plastic surgeons about ear reduction and they all say that it can’t be done without severe ear distortions and scarring, which is very disappointing to me. Like I said I have been to a few surgeons who specialize in otoplasty and what bothers me is mostly the top portion. I have found only one surgeon who has pictures of this procedure, unfortunately he is retired. Do you know of anyone who would be able to preform this? Thank you so much for your time, it is greatly appreciated.

A: The traditional method of vertical otoplasty reduction, through a wedge technique, would result in significant upper ear deformation. What you are demonstrating is a different technique, known as a helical flap method, which can reduce the upper 1/3 of the ear without such deformations. It is actually a technique borrowed from ear reconstruction from the resection of skin cancers in the upper helical rim which is a common location of such cancers. That would be the technique of choice when it is the upper ear that is the source of the vertically long ear. It places the incision/scar line at he favorable location of the underside of the crus and the junction of the helical root rather than directly across the helical rim at a 90 degree angle. It would reduce the height of the ear by 8 to 10mms which is a noticeable amount.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in skull reshaping surgery. Since I was young I always thought my head shape was oddly shaped making it unpleasant to cut my hair short, wear hats, or even have different hairstyles. I would like to know how long you have been doing this surgery because a surgery like this can go very right or very wrong unless someone is very experienced in doing it. I know that the same surgery is also done in Korea but I would rather not go so far. I always hoped that a surgery would be able to fix my head shape, I just never knew that there were surgeons out there who could do it. My head is flat in the back and is not even symmetrically flat as one side (the left) is more flat than the other. Please tell me what you think can be done.

A: There are many options in skull reshaping surgery. I would need to see some pictures of your head shape to determine what needs to be done exactly. But by your description it sounds like a case of a flat back of the head (occipital brachcephaly) with some asymmetry to it. Thus the surgical treatment would be augmentative as an onlay cranioplasty approach, probably using PMMA as the material as the volume addition would be at least 60 grams maybe more.

I have done many such skull reshaping surgeries, and many other variations of it, for over 10 years based on a lot of craniofacial plastic surgery and biomaterials experience previously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering facial implants to rejuvenate my youthful face. I am 27 years old and underwent gastric bypass surgery 4 years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye..I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows..I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change..not me I want a drastic change. I lost over 160 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I was wondering if you can preform an ear reduction surgery. My ears are very big (tall) and I would like them reduced in size. They have always been too big for my head and it has bothered me all of my life. I have done some imaging of ears to show my “desired” results, I understand that they might not be exactly attainable. Any information is greatly appreciated.

A: What you are demonstrating is vertical ear reduction. This is possible but not by the way you have imaged it. You have shown imaging where the upper third of the ear has been reduced which is an area of the ear that can not be reduced without disruption of the shape of the superior crus and helix which would give the ear an unusual shape…not to mention prominent scars. Vertical ear reduction must be done through the middle portion of the ear where the scars can be better hidden and the alignment of the outer helix and the antihelical fold can be preserved. Also that amount of vertical ear reduction is probably a little more than can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a subnasal lip lift problem. Wish I’d seen your website some months ago. Four weeks ago today, I underwent a sub-nasal upper lip advance (bull horn) by another surgeon. Pre-op I had a lot of distance between my upper lip and my nose and it meant that when I smiled, only my lower teeth showed .(making it appear that I was grimacing). I was advised that I had 21 mm of distance from the top of my lip to the base of my nose, and that I would  benefit from having 6 – 7 mm of tissue removed, in order to show more upper teeth, even when my face was relaxed. Sadly, although visual imaging was available, the visualization was not shown to me. (My mistake for not asking to be shown what I would look like with a lip lift). Although I was told that only 6 mm of tissue was removed, it appears that more than this amount was, in fact, removed. From the base of my nose (columella?) to the top of my cupids bow I have 12 mm of ‘space’ and (for a male) a ‘cupid’s bow’ that is a bit too pronounced. I feel extremely self-conscious, and have been limiting contact with friends and family ever since the surgery. At four weeks post-op, I would imagine that it is doubtful that my upper lip will ‘settle’ any further? Even a ‘gain’ of one or two mm would help things, although 3 mm would be perfect! Although I suspect that this cannot be repaired by replacing tissue, I wonder if surgery to my ‘dangling colummella’  of my nose would allow me to pick up an extra two or three millimeters of space between my nose and upper lip? Of course, not sure if that would ‘relax’ my upper lip so that I did not have such a pronounced ‘cupid’s bow’. Is this something that you have encountered in the patients of other surgeons, and if so, what (if anything) can be done to try to revise this undesired outcome? Incredibly, as you mention in your website, it really is a case of only a few millimeters.

A: In performing subnasal lip lifts, my general rule is to never remove more than 1/3 of the philtral length in females and only 1/4 of that length in men. In judging the amount of upper lip skin removal, it is always better to be conservative as one can always do more. If too much is removed, some skin relaxation will eventually occur (even up to six months after surgery) but there is no method to add more skin. This skin can not be recruited from the columella…hanging or not. You should keep working on stretching the upper lip with your fingers and tongue as you should be able to gain a millimeter or two over time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor infraorbital rim and paranasal implants placed last year. The recovery was uneventful, but I’m hoping for further augmentation that’s more suitable for my face. This is why I’m contemplating getting a custom made implant for the entire mid-face region. However, my biggest concern is with removing these implants. I understand that Medpor removal comes with its risks. Assuming that I’m willing to undertake these risks, can I just check if it will at all be possible to remove the infraorbital rim and paranasal implants? If so, what kind of soft tissue damage can I expect? Would any tissue resuspension be necessary, especially if I were to replace them with the custom made implants in the same surgery? Thanks!

A: Having done a lot of Medpor facial implant removals, I have yet to see an implant that could not be successfully removed. There really is no risk with their removal other than the swelling which naturally occurs afterwards which usually isn’t worse than the original implantation surgery. I don’t think there is any risk of soft tissue sagging with their removal particularly if replacement implants are being simultaneously inserted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just finish reading an interesting piece on your website regarding paranasal implants and premaxillary implants.  I am seriously considering having this procedure done you since you seem to be the resident expert in this field. While I am aware the difference between a premaxillary implant versus a paranasal implant, I couldn’t decide which one of the two would I need, or  if I need both. I personally felt that my midface is a little flat. I have had rhinoplasty done before with the hope to fix this issue and while it did improve my feature, but not to a point that I satisfied with.  I’ve attached a few photo of my profile for your reference. Hopefully after looking at them, you would be able to determine which of the two I need.

A: Paranasal implants and premaxillary implants are very close cousins as they are implants that augment the pyriform aperture area. The front of the pyriform aperture is the premaxilla where the implant is placed across the anterior nasal spine. Its principal effect is to open up the nasolabial angle as it pushes out the upper lip/base of the columella. The sides of the pyriform aperture is below the sidewalls of the nostrils where it joins the cheek skin and is where a paranasal or side of the nose implant has its effect. It builds up the base of the nose by pushing out this area to reduce its concavity. These implants can be used independently or in combination.

With your natural facial profile and shape, a combined parasnasal-premaxillary implant would help complete the effect that you thought you would achieve with your initial rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read an article about temporal muscle reduction and it said that 70% of their clients died after two years, due to the surgery. Now I don’t know if it was specifically talking about shrinking the muscle. My question is, has this procedure been tested safe for people, because us people should not be put under the knife for a surgery which has been invented just recently and doesn’t have enough evidence to know if it’s safe or not. And is cutting and shrinking the temporal muscle dangerous? will it cause infections, brain damage, dead blood vessels, cancer and so on…

A: When it comes to aesthetic temporal reduction, primarily by muscle reduction/shortening, your perception or readings on it (of which I am not aware anything has ever been written in the medical literature in regards to  aesthetic temporal reduction) are grossly inaccurate. You are obviously confusing intracranial vs. extracranial temporal surgery. Temporalis muscle reduction is very safe and effective. as it is done on the outside of the skull. The only issues are aesthetic, the need for a fine line vertical incision in the temporal scalp and how much tenporal reduction can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been looking into getting facial implants, specifically chin, cheek and jaw angle implants, now for quite some time. During my time researching these procedures I have come across many reputable sources of information, like yourself, and millions of internet experts professing to know the ‘truth’ of some sort of another regarding facial implants. Nowhere amongst all this are clear and unambiguous answers to some of the most basic questions. Hopefully you can provide these for me. My questions are as follows: 

1. If a chin, cheek or jaw angle implant is placed, the surgical wound heals, all is well and the patient loves the result several months after the operation, what is the likelihood that the implant will become infected years or decades later.

2. In your experience, if an implant is placed uneventfully can the patient then go on to live for decades having ‘forgotten’ about the implant, so to speak? I don’t want to have to come back to any implants later in life, I want to have my first cosmetic surgery and then forget about it forever.

3. Is the removal of an integrated Medpor jaw angle implant as difficult as it is said to be? Also, is there a silicone jaw angle implant that can provide the so called drop down effect?

4. There is a lot of confusion regarding cheek implants for men who want their cheekbones to flare out laterally. Do you think it is a deficiency in zones 1 and 2 of the malar-zygomatico complex that needs to be corrected in order to achieve the male model look? If so, are custom cheek implants capable of achieving this in the right individuals 

5. Individual implants will not make a person look radically different. Is this something that can happen, for good or ill, when several implants are placed at once?

A: In regards to your questions about facial implants ( cheek, chin and jaw angle implants), my answers are as follows:

1) The risk of implant infection is greatest in the perioperative period (first month or two after surgery) usually as a result of implant contamination during placement. Delayed facial implant infections are very rare. not impossible, but it would require contamination into the implant capsule like from a dental local anesthetic injection. Delayed infection risks are so rare that they are almost case reports for the literature.

2) If one has uncomplicated healing and is pleased with the size and symmetry of the facial implant result, having them will quickly become a ‘natural’ part of one’s anatomy and they will be forgotten as being a synthetic extension of one’s face.

3) Medpor implants,including those of the jaw angle, can be removed and I have removed many of them. They are much more difficult to remove than silicone implants but that is an issue of relativity. Silicone facial implants are so easy to remove that anything that is more adherent seems difficult.

New styles of vertical lengthening silicone jaw angle implants are now available. I designed them to provide a better implant material to that of Medpor. They are much easier to insert and replace/modify if necessary.

4) The concept of getting cheek implants to achieve any type of facial look is more ambiguous and harder to achieve that most would think. The cheek area is a complex four-dimensional structure and the interpretation of what is a pleasing shape is as variable as the anatomy of each person’s cheek bones. It frequently is not as simple as just pulling an implant off the shelf, regardless of its style and size, and the desired look is achieved. Even using custom designed implants is not a guarantee that the desired look can be achieved as the ability to translate a design to what it makes the outside of the face look like is not a mathematical one. Many men seek the so called ‘male model’ look which often but not always means a high angular skeletonized cheek look. You would have to define what cheek look you are after by using model pictures as examples. While all of them are models, many of their cheek shapes are quite different.

5) The more facial implants that are placed, if they are not properly sized, the more different one can look.

The one caveat I would add to all of this is a basic fact based on my very extensive experience with male (almost always young) facial skeletal augmentation surgery…such patients have a remarkably high revisional surgery rate which approximates 50% or greater in the first six months after surgery. These revisions are almost never because the implants have any medical problems but because many young men are impatient of the healing process and often are uncertain if they like the aesthetic outcomes of their procedures even if it is exactly what they thought they wanted. Thus, when you think about getting facial implants this revisional surgery issue is what you need to consider, not all the other concerns that you have mentioned which are fairly irrelevant compared to this consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital dystopia corrective surgery. I have vertical orbital dystopia as a result of craniofacial trauma when I was a child. There were no orbital bone fractures that I know of.The severity of my condition seems to be very similar to the case study posted on your web page. In your case study, you’ve seem to have done a orbital approach alone. However, research on the web has led me to believe that surgical correction for this deformity can be very complex as stated by these 2 doctors where one describes a very invasive intracranial approach. So my question is would you be able to perform the correction using an orbital approach alone. Attached is a picture of my eyes. I would guess that the right eye is at least 5mm lower than the left. I would like to know what procedure you would recommend.

A: Vertical orbital dystopia refers to one eye being lower than the other as a result of the shape or size of the orbital box (bones) in which the eyeball resides. A 3D CT scan can precisely determine the bony component of the orbital dystopia by looking at the periorbital bones. Generally in cases of 5mm or less orbital dystopia, this is completely correctable by an intra-orbital approach. This is done by building up the orbital floor and inferior orbital tim. In reading the comments from the other doctors, although well intended, they are not accurate in how smaller amounts of orbital dystopia can be treated. By your picture, you are correct in that the eye is about 5mms lower than the left and could be lifted by the described infraorbital approach. Be aware that as the eye comes up,  however, it will be further buried under the upper eyelid by a similar amount. This means that the upper eyelid will need to be elevated by a ptosis repair, either done at the same time or as a separate surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast implants done about one year ago.  I had textured silicone gel shaped breast implants placed under the muscle. They were 335cc in size. My breasts were A cup size before surgery. I would like to know if corrective surgery with bigger implants will create more cleavage.  have quite a small frame and chest. I would not mind getting bigger implants but only if they looked natural and the breasts did not move any further out to the sides than they are now.

A: One of the basic principles of breast augmentation surgery is that the breast implants merely take the breast features that one currently has and makes them bigger. Therefore, if one’s breasts are fairly widely spaced, getting implants will not create cleavage. It is clear based on your pictures that your breast mounds, small as they were, were more to the sides of your chest wall. That can clearly be seen by how far your nipples are to the side before and after breast implant surgery. With the placement of implants under the muscle, it is hard to create any semblence of cleavage unless one has breast mounds that are naturally close together. That being said, the question is whether bigger implants will give you cleavage. If you place large enough breast implants, you will likely end  up with more cleavage but they will not likely look very natural and will be oversizes for your frame. You are better off just accepting the good breast augmentation result you now have even if it doesn’t create the cleavage you want. That is where bras can compensate for what implants can’t do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I have a mentalis strain, my chin starts to dimple and looks somewhat “bubbly.” My chin looks pretty short and recedes to me , but I am happy with the size my lower jaw except for the receding and the strain. Will my lower jaw have to be wider to fix the problem or can i just simply have my jaw  moved forward enough to fix the problem without having to change the size of my jaw?

A: Most mentalis strains are the result of a short lower jaw, a horizontal bone deficiency. This makes the mentalis muscle ‘overwork’ to try and achieve lip competence. Whether this is best treated by a lower jaw advancement or just a chin augmentation depends on many factors including one’s existing occlusion (bite), how horizontally deficient the chin position is and what effort one wants to put in to treating the problem. The width of the lower jaw/chin has no impact on the cause of the mentalis strain or in the treatment of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would a lip lift benefit my facial features and add more symmetry to my face?  Is there any other procedure that would make my features more attractive? How many of lip lifts do you do yearly? Do you have more before and after pictures of this procedure. How much increase in lip size would I achieve with this procedure given I have very thin lips? Thank you.

A: A lip lift can be aesthetically beneficial for those patients, women and men, that have a long upper lip with little accentuation of the cupid’s bow. As a general rule, about 1/4 up to 1/4 of the vertical skin distance can be removed. Women generally want p to 1/3 the distance while men are close to 1/4 to avoid to an over elevation of the cupid’s bow area. Lip lifts are very common in my plastic surgrey practice and I usually perform 1 to 2 lip lifts per month

In regards to other potential facial improvements, I have looked at a tip rhinoplasty with nostril narrowing and buccal lipectomies with perioral mound liposuction. There are are destined to help create a facial slimming effect as your face is naturally more round. I have included these in the attached lip lift imaging projections as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an unusual form of skull reshaping.  I am currently investigating possible procedures that could change my skull contour. I have congenital skull asymmetry/tilt, and have attached a simple drawing approximating the current shape of my skull. The area I would like to treat is on the left side of my posterior skull/occipital bone. If possible I would like some reduction of the skull near the occipital bone/protuberance and nuchal ridge on that side. In addition to this I would like to increase the volume beneath the ridge with a fat transfer. The goal of this would be to make it appear as if the nuchal ridge was lower on that side than what it actually is. My understanding thus far is that a solid implant would not be suited to this area as it could not be secured and it would have to lie on top of tendons/nerves and I’d prefer a more long lasting treatment over temporary fillers. Assuming there is enough bone that some can be safely removed, what amount (i.e. how many mm) can this part of the skull usually be reduced? I’ve seen photos of fat transfers treating various defects on different parts of the body and am curious how much projection could potentially be possible. The area I would like to increase volume in is roughly 2cm wide and 7cm long with varying depth. The depth would vary up to a max of 1cm. I know that fat transfers are unpredictable and can take multiple sessions, but I’m curious is this would be potentially feasible. My weight is stable and does not fluctuate much. In your estimation would these procedures be technically possible or something that you could potentially perform? I would very much appreciate your input.

A: Skull reshaping can be done for a wide variety of bone issues. The area to which you want to reduce is known as the nuchal ridge of the occipital bone. It is actually where the posterior neck muscles attach to the skull. As a result it is very thick to accommodate the pull of these strong neck muscles, illustrating the biologic principle of form following function. This is why it is a raised edge of bone and can be substantially reduced in its prominence by a burring technique. As for augmenting the area below it, fat injections can be done but I would have little confidence that they would create, even if they survive, a raised ridge presence. You would be better served to have an actual implant placed down that low and secured to the bone. Since some of the neck muscle tissues has to be released anyway to do the burring, it would be more reliable to attached a small silicone implant with those dimensions to create an assured permanent ridge effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22 year old man who is interested in custom facial implants. I have taken an interest in your practice because of your really detailed and informative website and photos and because of the experience you have with the particular facial implants I want done. I am interested in getting cheek and wraparound jawline/chin implants. I want the cheeks implants because my cheeks are quite small and I would like to have implants put in to make them larger and have a more sculpted face. As for my jawline and chin, it is quite small and narrow and I would like a wraparound jawline implant to give me a stronger wider jawline, a sharper jaw angle in the back, and a larger chin that are seamlessly connected together. I know this will require a custom implant approach to get the best implant symmetry and shape, provide a faster operating time, and provide me with a better chance of obtaining the results I am looking for. I want to know if these two surgeries could be done at the same time? I am really looking for a more masculine sculpted jawline and chin and cheekbones that provide a youthful face as well. I am really interested in you performing the surgery since so far you seem to be the only surgeon I have searched online who has a blog devoted to helping answer clients questions and you have an extremely thorough website.

A: You are correct in assuming that a custom facial implants is the best way to go when one seeks a wrap around jawline implant that is seamless from front to back. While off-the-shelf cheek implants could probably be used, one might as well make the cheek implants custom as well since that would add little cost as the 3D CT scan and software design process is already in place. It would be very common to do cheek, chin and jawline implants together to achieve a comprehensive overall facial enhancement result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in a geometric broken line closure scar revision but I have a few questions.

1) Would you do multiple layer closure underneath the skin to ensure that there is proper wound undermining. If so many layers?

2) Since I’d be an out of town patient could you use dissolvable sutures on the outside?

3) Would dissolvable sutures affect the outcome negatively or it shouldn’t?

4) Is there anything you can do to help prevent the scar incision becoming indented and the outside edges looking raised?

5) Do you normally have to perform dermabrasion after the GBLR and if so when would this be performed? Would it cost more if I had to do dermabrasion later.

6) Given the size and location of my scar right in the middle of my cheek in your professional opinion do you think that GBLR is my best option? I just worry having different zig zaggy shapes might be more noticeable than a straight line but the problem I have with the straight line is how the edges are raised.

7) I had scar revision done 7 months ago do you think that it is ok to do another revision now since I know the raised edges won’t get better or do you think it’s too early?

A: In answer to your questions about an irregular or geometric broken line scar revision:

1) Every plastic surgery wound closure uses multiple layers.

2) Yes

3) No

4) That happens when there is scar widening. Interdigitating the scar limbs, like in a GBLC, helps prevent that.

5) Whether dermabrasion is needed later depends on how it heals. I would say the risk of that is way less than 50%. It is something that I find uncommon to need to do. Maybe a light laser resurfacing but not dermabrasion in your type of facial scar.

6) Your results with straight line closure have proven that approach is not adequate. It is either GBLC or leave it alone and accept its current appearance.

7) You do a revision when one is certain that no further improvements are going to happen with further healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a bullhorn lip lift. No one can ever see my teeth when I talk or smile and it really bothers me. I have already had orthodontics and lowered the front teeth as mush as possible and still no one can see them. Are there any bad side effects of this procedure? Would this procedure correct this? Email me please.

A: While lip lifts are most commonly done in women, there are some men who benefit as well. Your smiling and non-smiling pictures show that you are one of those men. Your upper lip is very long and your upper lip vermilion is thin and pencil-like. Such an upper lip anatomy can mask most of the upper teeth which will largely be unaltered despite dental manipulations such as orthodontics and tooth lengthening by veneers or crown lengthening. A bull horn or subnasal lip lift would help in in that regard by lifting up the center part of the lip via shortening the nose to lip skin distance. This can be very effective as long as it is not overdone (too much skin removed)  and the lower edge of the upper lip line remains level. As an isolated procedure, it is usually done on the office under local anesthesia with minimal upper lip swelling afterwards and no real recovery. When the incisions are well placed along the alar base-lip junction, they can heal in an undetectable fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-straight line scar revision. Attached are some pictures of my facial scar.. I marked up some pictures with a horizontal line showing how it is raised on the side of the scar nearer my nose. Do you think that it would be possible to remove the raised skin on the inside of the scar near my nose or do you not think that would be necessary. My goal would be to smooth it out as much as possible where we could get rid of raised part as well as indented part on the incision line if possible. Note I am happy with how narrow the incision line is, I’m just not happy with how raised it is around the incision and I’m wondering if you think that a GBLR might break up the line to make it less obvious or if you think I should just try dermabrasion first to smooth it out.  Also do you think a GBLR would be best or a straight line closure in the area of the cheek? I think the scar size is around 2 and a half cm in length.

A: Your prior straight line scar revision demonstrates the drawback of this approach in a facial area that does not parallel the relaxed skin tension lines. The scar line may be narrow but the edges around it are raised and visually obvious. With geometric broken line closure, the scar is also narrow but the edges do not usually get raised as the scar line is interdigitated and the contractile forces on it are better dissipated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting  tummy tuck.  At about this time three years ago, I had a miscarriage at five months. Unfortunately, my body never really recovered from all the changes it went through. In the last three years I managed to lose about half of the weight I put on. It seems that no matter how much I try I can’t get back to normal. I’m about to graduate college and start this wonderful new chapter of my life, but I’m afraid that being stuck with my pregnancy figure will keep me from fully enjoying it. I’ve attached a couple pictures of myself for you.

A: Based on your pictures, you have an ideal stomach issue for a tummy tuck and flank liposuction. With your body now, your stomach could end up completely flat and your waistline would have an hourglass shape from the liposuction. The trade-off for this abdominal and waistline change is the low horizontal scar that accompanies every full tummy tuck. This is an issue for every woman to consider that has not yet had children and may likely do so in the future. But besides the aesthetics of the scar, it does not prevent future pregnancies nor does it affect the ability to carry a child to full term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking steroid injections after gynecomastia reduction surgery. I had gynecomastia surgery almost two years ago. The surgery was fine, but of course I dealt with scar tissue problems afterwards. I got Kenalog shots and it really reduced it alot! I have a bout a pea size piece sticking literally right behind the nipple itself. When my nipple is hard or semi hard the scar tissue is jagged and literally sticks out just like my nipple (protruding my nipple out too much for me to live with for the rest of my life and extremely bothers me) But this is so small for surgery so I don’t want to risk it. I was wondering if you would hit me with a 5FU or 5FU/Kenalog controlled shot to flatten this jagged connective tissue that makes my middle nipple area still stick out.

A: It is very common after gynecomastia reduction surgery to have scar tissue form behind/beneath the nipple. When the initial gynecomastia problem is relatively small, any nipple scar tissue formation can leave one with a still persistently nipple protrusion problem. In the first year after surgery (really the first six months) steroid injections can be very helpful in breaking down any scar tissue formations. After one year the success of steroid injections to reduce prominent scar tissue diminishes considerably as the bonding of the collagen in the scar tissue becomes very mature. There is no harm in doing further steroid injections but be aware that the success of them at this far out from surgery may not be like what had occurred earlier after surgery. Should this fail you should consider a small revision through an open incision under local anesthesia as an office procedure. This can remove the problematic small area of scar with little risk of recurrence. I have done this numerous times in secondary areolar gynecomastia reduction surgery.

Dr. Barry Eppley

Indianapolis, Indiana