Your Questions

Q: Dr. Eppley, I have a question about paranasal implants. May I ask what do you think about fat graft to the sunken paranasal area ( and a malar implant on top)? Will fat grafts ( say inclusive of a few touch ups ) have the same effect as a paranasal implant?

A: Fat grafts by themselves will not have the same effect as paranasal implants. A solid implant on the bone can very effectively push outward on the overlying mid face tissues. (it has a more rigid structure that the tissue that it is designed to displace) Conversely, a fat graft is soft and does not have the same degree of push (augmentation) as a solid implant. The overlying soft tissue has the same structural rigidity as the fat graft so there is some rebound effect and less defined augmentation than one would think. In addition, the retention of a fat graft is unpredictable.

Thus fat injections are not a comparative ‘implant’ to that to a true paranasal implant. For those opposed to the placement of an actual facial implant, fat injections are the only other option and are not unreasonable…it just does not create the same effect as a paranasal implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery. As you can probably tell from the pictures I have attached,  I suffer from Alopecia areata. I realize there will be a scar from the coronal incision, but I have no reference for how bad the scar will be. Would the trade off be worth it? I look forward to your assessment.

A: When it comes to brow bone reduction surgery, the degree of brow bone protrusion is important as that determines whether surgery is worth it and how it might be done. You do have a Grade IV brow bone protrusion which aesthetically is very severe so I can understand your pursuit of brow bone reduction surgery. A dramatic change in your forehead can be obtained through a combination of a brow bone reduction via an osteoplastic bone setback and a little forehead augmentation just above it. The very legitimate question is whether the scalp scar trade-off is worth it. I certainly have done a significant number of forehead and skull reshaping surgeries on men who shave their head or are otherwise bald but always do so with great trepidation. Since much of aesthetic surgery is always about trade-offs, one has to be sure that what one is trading off into is better than the initial problem. I can not make that decision for any patient as only they can place those type of values, all I can do is provide information that may help in making that decision. I will send you a picture of the scalp scar from a brow bone reduction patient who largely was bald across the top by tomorrow. This may help you in making that trade-off decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an injectable rhinoplasty. You probaby can’t tell by the pictures so much, but I have a droopy tip to my nose. The bridge is fine but from the frontal view it droops and I am wondering if it could be lifted up by injection fillers.

A: An injectable rhinoplasty can be very effective if used for the right nose problem. While injectable fillers can be placed into the tip of your nose, they will make it somewhat bigger in an effort to lift it which may be viewed as aesthetically counterproductive. It would be more predictable to do a simple tip rhinoplasty where the tip could be reliably lifted and avoid making the size and width of the tip any bigger. A droopy tip in a thick skinned male nose is not a good indication for the use of injectable fillers in nose reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a chin implant revision. My surgeon used a 10mm Medpor chin implant. My face was round and small before, now its very long and wide so I look masculine. I’m female by the way. Is 1 month too early to tell? The shape of it has not changed since the first day after surgery and I hate it. I have attached some pictures of me before surgery and the way I am now.

A: The timing of a chin implant revision depends on when one is certain that its size and shape are not satisfactory. Even though it is just one month after surgery, if the chin augmentation looks too big and wide to you, it is because it is. I usually use the benchmark period of six weeks after surgery for one to have 90% of the facial implant result. Medpor chin implants have a very poor taper to them due to the material thickness and their extensions backward along the jawline are destined to make many women have wide looking chins. A large 10mm implant is most assuredly going to cause this widening effect. While you clearly appear to have been a good candidate for a chin augmentation, I am afraid that you appear to have the wrong implant style for your female facial features. Both your pictures and how you feel at this point indicate that clearly this is the case. I would suggest that you have a chin implant revision that either has the existing chin implant reshaped or exchange it for a chin implant that better matches your feminine facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in CO2 laser resurfacing and skin under my eyes and also to remove dark spots on my cheeks. Or maybe I need a pinch blepharoplasty instead. I had a lower blepharoplasty three years ago which left my eyes more wrinkled. I was told this procedure would remove the fat and then cut and tighten underneath. Only the fat was removed. I’ve load an up close picture which also shows the spots and a smiling picture you can see how much extra skin is under my left side, which makes me not want to smile as it shows worse when I do. 

A: By your description your original lower blepharoplasty sounds like a transconjunctival one in which no skin was removed but only fat from the inside of the lower eyelid. By deflating lower eyelid ‘bags’ (fat), skin wrinkles are often worsened as the skin retracts. This is why many transconjunctival lower blepharoplasties often include a simultaneous skin resurfacing procedure (laser or chemical peel) to avoid this aesthetic problem with fat ‘deflation’.  At this point, you need a pinch lower blepharoplasty, as you have surmised, to get rid of the roll of skin and muscle that is just under your lashline. With smiling not all of the extra skin can be completely removed but a significant improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking into buccal fat pad removal (buccal lipectomy) and possibly perioral mound liposuction. My face holds a lot of weight compared to my low body fat percentage. I workout consistently and follow a very precise diet but no matter how hard I try I can never seem to lose the fat on my face. I am self conscious and try not to smile in public as smiling makes the fat on my face more apparent. My father and my grandfather both have the same issue. I would like to know your opinion on what could be done to improve my appearance. I would really like to have a thinner face, similar to that of a male model.

A: I think your face would benefit by a buccal lipectomy and perioral mound liposuction to provide some improved contouring. Whether that would be enough of a change to give your face the ‘male model’ look is a more indeterminate question. It would definitely be beneficial in that regard, and you have the right face for these procedures that will best show their effects, but the male model look per se may be asking more than is possible. That, of course, depends on how one expects that type of face to look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in paranasal implants. I am a young Asian male residing and am looking forward to hearing your experience and expertise in facial deficiencies. I have a slightly retrusive face with deficiency in the maxillary area and slightly in the paranasal area. I am considering doing both procedures. However, I have some questions that I hope you could assist me in answering based on your experience:

1) Can paranasal implants make the nose slightly upturn? ( I’ve seen complaints of such occurrences)

2) Will the paranasal implants cause stiffness when smiling AND change the shape of the upper lip (I’ve seen before and afters and I noticed that the upper lip tend to be thinner). Because even with my slight midface deficiency, everyone says I have a very attractive smile and I am very afraid to risk losing that. ( I would like to change the tired look when NOT smiling but maintain the current smiling face )

3) Will maxillary implant alone reduce the dent in the paranasal area ( beside the nostrils ).

4) Is at grafting and maxillary implant be possible ( and long lasting enough? )

Really hope you could help answer the questions to the best of your knowledge. 

A: When it comes to midfacial implants, let me carefully define the terms, paranasal, premaxillary and maxillary implants. These three implant terms are often used almost interchangeably but they are three distinctly different regions and implants for the midface.

A paranasal implant, which wraps around the lower pyriform aperture area, augments the base of the nose under the nostrils only. (also softening some depth of the upper nasolabial fold seen externally) It does not cross under the base of the nose or under the columella or on top of the anterior nasal spine. Thus, a true paranasal implant will not may the nose upturned. Because it is placed on the bone, under the facial musculature, it does not thin out the lips and has a very low risk of any change to one’s smile. (once beyond the temporary swelling and stiffness that typically occurs in the early after surgery period)

A premaxillary implant, often confused with the paranasal implant, goes across the base of the nose under the columella. (to add to the confusion there are combined paranasal-premaxillary implants) Historically such implants have been placed from inside the nostrils, above the bone and directly into the orbicularis muscle of the lip. It is this premaxillary implant that undoubtably gives rises to upturned nose, stiff lips and altered smiles. While a premaxillary implant can be placed right down on the bone and across the anterior nasal spine from inside the mouth, caution must be given to the size of the implant to prevent these nose and lip problems.

A maxillary implant (and one can argue that the paranasal and premaxillary implants are forms of maxillary implants) is an implant that extends beyond the paranasal area across the face of the maxilla and then sits just under the cheek bone. It is a rarely used implant as it has a midfacial volumizing effect between the base of the nose and the cheek prominence.

As you can see by these proper descriptions, it is easy to confuse the effects of these midfacial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin implant, jaw angle implants or both. I believe chin implants/jawline  implants come in different dimensions or sizes? Would it be better to do one procedure at a time? What face shapes are good candidates for this type of procedure?

A: A chin implant and jaw angle implants come in a wide variety of styles and sizes so there is a range of changes that can be done. The purpose of computer imaging is to first see whether these type of facial changes and their magnitude is what someone is looking for. Different implants will create different degrees of change.

When it comes to elective facial surgery, you do the procedure in which you are absolutely convinced is needed. Any procedures in which you are uncertain you wait and see how the first procedure affects the facial area of uncertainty.

The best candidates for chin augmentation is just about any face because it is a ‘edge’ or profile procedure that would improve any face in which the chin is short. Conversely, jaw angle implants work best in thinner faces where their effects enhance or skeletonize the face as opposed to a fuller or rounder face in which it may just make it more bottom heavy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in a revision rhinoplasty. I had excessive swelling after nose tip rhinoplasty; nose tip looks great, but my formerly thin nose is much wider and uglier above the tip; and very damaging to me psychologically. I have had two Kenalog (diluted) injections within 15 to 18 months post-op, with limited results. I am completely aware of the risks of revision rhinoplasty. Please advise on whether further kenalog might help, or would recommend a revision.

A: At over one year after a rhinoplasty, there is not going to be much of a change from any form of steriod injections. Steroids or even 5FU work by either preventing or helping to break down early scar tissue formation. This can occur when the collagen bonds are relatively newly formed. But when the scar is mature, as it would be at one year after the initial rhinoplasty, the collagen bonds are too stable to be pharmacologically broken down. Whether a revision rhinoplasty will help thin out a nose above the tip in the middle vault area or higher, however, is suspect. It is not like in the tip where scar tissue can be easily removed and additional reshaping of the cartilages can be done. There is also the distinct possibility that with a more narrow tip, the rest of the nose above it may merely look bigger by comparison. That may not be a major component to the existing nasal issue, but it may be part of it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am wondering if chin reduction may be helpful for me. I had a chin implant which I was not keen on so I had it removed. It’s been two months now and the chin is not what it was, it looks more masculine and wider than it was originally. Do you think that this will improve?

A: A chin implant adds volume to the bone as an onlay but do so but stretching out the soft tissues of the chin that is on top of it. Thus, when a chin implant is removed, it requires the overlying soft tissues to shrink back down and readapt to the bone. Whether that can happen successfully is influenced by how large the original implant was, how long it was in and what the surgical approach was to place it. (submental vs. intraoral) I don’t think you can have an absolute certain answer for three to four months after its removal, but in many cases the chin will not return to its original shape. Even though it has only been two months, I would not be optimistic based on how your pictures look. Chin reduction surgery may be beneficial in chin removal cases like yours as it removes and tightens the loose soft tissues and may contour the chin bone as needed for additional chin shape contouring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an indented scar on my cheek that needs some type of scar revision. It started out getting an injectable filler treatment (Restylane) that got infected. After antibiotics cleared the infection a few months later the area appeared indented and became a samll atrophic scar.  It then had V-beam treatment for the indentation several months later but only became more indented. It lost whatever fat it had. It is an area under the eye where the cheek fat pad starts where there is a circle that is indented. One surgeon said there is no fat there and that is why it is sunken. I want to know if there a full thickness fat graft or some type of soft tissue implant that can be used to fill it?

A: The scar revision to which you refer is really the need for fat volume restoration. It sounds like you have a distinct area of fat atrophy with scar contracture on your cheek. While this is water over the dam so to speak, the use of a V-beam treatments was ill-advised for that type of depressed scar and did exactly what could have been predicted. That issue aside, options include fat injection or the placement of a small dermal-fat graft that treats exactly what the problem is…lost fat volume. Fat injections involve no incision or harvest site but are somewhat unpredictable in terms of volume retention and do not do a good job of releasing and scar contracture. A small dermal-fat graft would be more effective but it has to be placed somehow through a small incision and requires a harvest site which could be behind your ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can Jaw and/or chin implants give me more of a chiseled/angular/square longer lower face? I don’t want to have the procedure if it can not create this kind of look.

A: In the right type of face, chin and jawline implants can indeed create a more angular or chiseled look. The right type of face is a thinner or lean one that can show skeletal highlights better. Fuller or ‘fatter’ face can not get a more chiseled look from facial implants as the soft tissue cover is too thick to show their outlines. This is particularly true of jaw angle and cheek implants which are facial locations that do not jut out like the chin can.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be very interested in getting hip implants. My hips are tiny. I would like to add an inch to both sides of my iliac crest closer to the front part. Too bad there isn’t a good way to secure them to the iliac crest- I would gladly take scars over my little boy hips for that implant to be rigid!

A: Hip implants are so of a vague term as it could imply areas from along the iliac crests to do over the hip joint. (upper thigh) I would call true hip implants as you have defined your hip concerns…up over the iliac crests. Augmentation could be done by fat injections or actual implants and each as their own distinct advantages and disadvantages.  For certain volume retention, an implant is the most assured approach. There are no true commercially produced hip implants but the shape of a calf implant would be ideal for placing on top of or along the edge of the iliac crest. As a long cigar-shaped implant that would be almost an inch thick, a one inch increase on each side of the hips could be obtained. This does require a 1 to 2 inch incision at the front end of the iliac crest to create the tunnel and place them. A single screw could be used to secure the implant to the iliac crest if desired. The only question is whether that is absolutely necessary or not. The long-term stability of the implant over the iliac crest has not been established given the rarity of this type of body implant procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implants. Please find my two photos. First one is my face, which is ok I think but it is the second photo which kills me. You can see the nasolablial fold and the cheek skin/fat falling down my face, making me look fat and old. I need to fix this and want to know my best options. Is it cheek implants? Paranasal implants? (whenever I push my top lip forward with my tongue from inside the mouth, my nasolabial folds and falling cheek fat disappear. Please let me know my best option sir. I don’t want to look like a fat guy even though I’m skinny. It’s just like my face is falling. I think I lack the bone structure to hold up my face. As my jaw and cheek bones are non existent. I am 32 years old. Thanks!

A: At your age I don’t know that your face is truly falling but I would not disagree that you have weak cheekbone structure. Pushing the lip out is not a practical approach to improving your facial structure. The only way to get some tissue lift is through cheek implants which will create a bit of a midface lift using malar shell implants. This will not eliminate the nasolabial folds completely but it will provide better facial balance and make your face look less fat. In addition I would do fat injections into the nasolabial folds and the paranasal areas to provide some augmentation to them as well. This in combination with the cheek implants will likely create the overall facial improvement you seek.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin augmentation. I am a 52 year old male in good health with no serious medical conditions. Three years ago I had a platysmaplasty, rhinoplasty, lip lift, and implants in my chin, jaw angles, and cheeks. The chin implant subsequently became infected. The infection resulted in the removal of the chin and jaw angle implants several months later. Only the chin implants remain. My primary concern now is that my chin appears weak. I’m also concerned about the sagging appearance on underneath left side of my chin and the very visible scar below my chin from the previous surgeries. Regarding the jaw angle implants,  I understand that my posterior mandible is quite narrow, but my eyes are also narrowly set and jaw angle implants accentuate that feature. I learned this clearly from the very wide jaw angle implants I had from my first surgery. So, jaw angle implants are problematic for me for that reason. Also, the chin and jaw angle implants that I had moved significantly after surgery, which I would also like to avoid with any subsequent implants. Please let me know if you can fix any implants with screws so that they do not move.

A: In reading your history, you have lost the benefits of your chin augmentation due to infection, your implants shifted after surgery and the jaw angle implants were an aesthetic detriment. In addition the submental scar is very wide and there is a little tissue sag on the left side of the chin.

A new chin implant can certainly be done and I almost always secure this in by double screw fixation. This could be put in from your existing submental scar. Your submental scar is wide because it has been placed behind the submental skin crease in the skin of the neck. This is not an ideal location as horizontal incisions in the neck skin tend to widen. The best that can be done with that scar is to excise it completely and hope that it heals more narrow this time. A new chin implant should pick up any loose skin along the jawline.

Jaw angle implants are more than just about widening the jaw angle as you appear to have had lateral widening jaw angle implants used. There are also different styles of jaw angle implants that merely make a pronounced jaw angle without making it wider. You may initially have just had a wrong style implant used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a rhinoplasty that can get my nostril size reduced. I would like to reduce how much of my nostrils you can see from a front profile ( basically bring the front of my nose down). Lastly I don’t like how you can see in my nostrils from the side profile. Does this all seem possible?

A: From a rhinoplasty standpoint, the size of one’s nostril’s is controlled by several anatomic factors. These include the length of the lower alar cartilages, the amount of caudal septal support, the angulation of the lower alar cartilages away from the dome and the width of the nostril base. When looking at your nose, the main reason you have a lot of nostril show is that the length of your nose is short making the tip of your nose rotated upwards. (which is why there is excessive nostril show in the front view) In addition, you have alar rim retraction with a bowed rather than straight alar edge. (which is why these is too much nostril show in the side view)

To increase your nasal length and decrease nostril show, your rhinoplasty must have increased structural support. This is done through cartilage grafts, harvested from the septum or ears, placed to push the tip of the nose down (septal extension graft) as well as along the edge of the lower alar cartilages. (alar rim grafts) You may also benefit from nostril narrowing as well but that can only be determined by a front view picture which you did not provide.  I have attached some imaging to show what this type of rhinoplasty can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,Is wisdom teeth removal a prerequisite for an osseous sliding genioplasty? Also, how much does your practice charge for an osseous genioplasty (with hospital fees + anesthesia)? 

A: There is no correlation between a sliding genioplasty and wisdom teeth, whether they are removed or not. The chin is located on the front part of the jaw while the wisdom teeth (third molars) is on the back part of the jaw. You may be thinking of a sagittal split ramus osteotomy (back of the jaw osteotomy) where having impacted wisdom teeth out six months before the procedure is needed as the embedded tooth roots may interfere with  successful splitting of the bone and plate the screw fixation to hold it together as it heals. In fact, wisdom teeth removal can be done at the same time as a sliding genioplasty if necessary.

A sliding genioplasty is done as a one hour procedure done under general anesthesia in a surgery center not a hospital. The usual total fees are around $6500 for all involved costs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a hairline advancement. I have been looking at your website for a while and you’re the only doctor I’ve found who may be able to perform the surgery I want. My forehead sticks out and bit and I would like to shave it down just a little to make my forehead flatter. I was wondering if this would be possible judging by the images I’ve attached. I’m also thinking I’d like to get my hairline advanced just a little bit. The area I’ve shaded is about the area I’d like to get it reduced to.

A: It is very common for a frontal hairline advancement and a bony forehead reduction to be combined together to create the changes you have shown. You have mentioned that you want just a ‘little hairline advancement although your images show a hairline advancement that I would judge to be up to 10 to 15mms. (which for a hairline advancement would not really be judged as little, that is usually the very maximum that can be achieved in a single stage procedure in just about anyone and even that depends on how much natural laxity of the scalp one has.

What is not very common is to have a male request or to actually do a male hairline advancement. I have done them it, it is just a procedure that is much more commonly done in women. The reason being is that most women have a stable frontal hairline while that is certainly not assured in men. This there is always the concern about placing a fine line scar along a hairline that may or may not be there in the future. While there is no alternative to having an incision to do a bony forehead reduction, there is an alternative (hair transplantation) to a hairline advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think I am interested in a browlift. Recently I have seen major changes to my face. I have been very lucky to always have been told I look younger and more youthful than I am but time has finally caught up with me. As you can see my eyes look tired and I look puffy. I also have always had a duck lip! I tried fillers but as you can see it made it worst. I am looking forward to looking refreshed and as young as I feel. I have started a six month lifestyle change, going to the gym three to four times a week, cutting out sugar and smoking over the next couple of months and studying natural/ holistic food. I feel beautiful until I look in the mirror and I know the potential I could be with a few minor adjustments. I am interested in seeing if you can see this too! I never expect to be a model but would like that twinkle in my eye again. I am looking forward to reviving my youthful look. Looking forward to hearing your suggestions.

A: As all of us age the first changes that are seen are around the eyes. Excess skin develops on the upper eyelids, the lower eyelids become puffy and, for some, the eyebrows drop. Rejuvenation of the aging periorbital region could include upper and/or lower blepharoplasties and browlifts, depending upon which areas are of the greatest concern.

Based upon the one picture that you have sent, it is hard to say what the ideal procedure (s) is for around your eyes since it is only a side view. The upper eyelids shows a little bit of excessive skin, the lower eyelids may actually have some tear troughs and the brows may or may not be low since I have no idea what you looked like years ago. My suspicion is that maybe a browlift and little skin removed from the upper eyelid and fact redistribution on the lower eyelids may suffice…but a few more pictures would be helpful.

For the upper lip protrusion, I would have expected injectable fillers to have made it worse. You would be better served with an upper lip lift which would reduce the protrusion somewhat but also give the upper lip a little more fullness. But again a front view picture would also be helpful in deciding if a lip lift will really be beneficial or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in ankle liposuction. I am in good shape but have my mothers lower legs:(. No definition between thick ankles and calves) I live in another state so driving in for a consult won’t be possible with 3 small kids.  I liked the pics on your site, your work looks great!  Just want a ballpark figure so I can see if its in our budget for after the holidays.  I can send pictures of my legs, but they are typical cankles.  Not large, just not shapely.  I run 1/2 marathons and compete in triathlons… Nothing helps give me a calve or smaller ankle.  Thanks so much!!!

A: You undoubtably are referring to what is historically known as ‘cankle’ liposuction also known as ankle liposuction or ankle liposculpture. There would not a reason to come in for a consult. Pictures can tell me exactly all I need to know. Creating some definition between the calfs and the ankles is a minor liposuction procedure that narrows the inner and outer ankle widths. The procedure is fairly simple to perform and would cost in the ballpark number of around $4,000. The biggest issue with ankle liposuctiopn is that swelling will persist in the ankle area for awhile and the final result may take as long as three months to see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question on custom designed facial implants. I had custom designed jaw angle implants made that go from the jaw angle to the chin. I want them placed only through incisions from inside the mouth and no incisions on the outside. My original surgeon said that he could only get them in from an external incision which surprised me. I do not want that scar. Can you get them in from just inside the mouth?

A The custom design method for facial implants is truly amazing when visualized on a computer screen. The ability to create any shape and thickness of an implant and match the symmetry between facial sides, if needed, is impressive. But one limitation of computer designing implants is that it is done on an inanimate facial skeletal computer image that does not take into account the soft tissue cover…nor how such designed implants may be capable of being placed. Given that placing facial implants must be done in an inconspicuous and visible scar-free manner, being able to get a custom designed implant through the limitations of intraoral or discrete external facial incisions can be problematic.

Custom designing facial implants often allows larger and more encompassing implants to be created. But part of their design must take into consideration how they can be inserted and whether the overlying soft tissue cover will be adequate and still get the incision closed in a tension-free manner over it.

I have found it useful in many custom designed facial implants to have them sectioned or cut up into smaller implants so that they can be inserted from just inside the mouth. All sectioning the implants does is enable them to be placed through intraoral incisions. It does not affect the accuracy of their placement and, in some cases, may actually make them more accurately placed. One of the things you learn by doing a lot of custom implants over the years is that anything can be designed on a skull model or a 3D scanned image. Whether they can actually be placed (inserted through the limits of the incisions) and with good soft tissue cover, elements in the surgery that are often more important than the design for an uncomplicated result, is often another matter and must be considered beforehand to avoid an unpleasant intraoperative surprise.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a questions about gummy smile surgery. I am a 25 year-old female. I have an upper jaw prominence as well as a gummy smile. It shows 8 mm of the gum. I went to a dentist to do a lowering lip surgery, however, he said that even if he would do it for me the gummy smile will go back once more time because of the upper jaw prominence. I end up thinking what if  I do a V-Y flap or a W technique for upper lip lengthening?. Are they going to work in my case and last for good? Or there will be a relapse because of the upper jaw prominence. I hope you get my point. Thank you.

A: When it comes to gummy smile surgery, the potential for relapse is related to the surgical technique not how much upper jaw prominence one has. The key to preventing relapse in upper lip lengthening is the vestibuloplasty portion of the procedure. Shortening the depth of the vestibule will serve to keep the upper lip from relapsing back to original position. Going to a dentist is probably not the best doctor to have treat a gummy smile that is so excessive which is probably beyond their comfort zone and experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have linear scleroderma which affects my forehead  and would be interested in discussing how it could be treated. I’m 44 and balding, so the scar is much more prevalent than it had been when I had more hair. According my doctor out here, it’s burned out. I’d like to learn more about your experience with this problem and how you might look to correct it.

A: Your linear scleroderma involvement of the forehead and scalp is fairly classic, going down (or up) along the pathway of the 1st division of the trigeminal nerve. At your age it would be fairly common that the disease process has burned itself out. There are numerous approaches to the reconstruction of the aesthetic forehead defects from it, most of which focus on volume restoration using various forms of fat grafting. The problem with that exclusive approach is that it can not restore the quality of the overlying skin which is usually thinner and discolored to some degree. Even with volume enhancement, the vertical orientation of the involved skin is still very apparent.

In your linear scleroderma case, I would use two different surgical techniques which are different. On the forehead, I would excise the entire length of the involved skin and put the closure back together in a broken line closure methods due to the numerous horizontal wrinkle lines that you have. This would be an ideal way to really hide the scar well. This would not only ensure a permanent and assured resolution to the forehead soft tissue defect but also gets rid of the deformed skin. On the scalp, however, a different approach would be used as it is smooth skin with no wrinkles lines to help hide the scar. I would do fat injection grafting to restore the indentation only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in liposuction or perhaps one of the non-invasive body contouring approaches. I am a petite 23-year old female who is 5’4” tall and weights 112 lbs. I am in pretty good shape, but have areas of fat on each of my inner posterior thighs that will not go away with any form of exercise and have been there all my life. I would be very happy with a visible reduction of this area and the bulges eliminated. I am also very apprehensive about any procedure requiring general anesthesia and would greatly prefer to reduce risk. But on the other hand, I don’t want to waste money on noninvasive treatments that don’t offer a significant improvement.

A: Liposuction would be the most efficient and effective method of fat removal for your inner thigh areas. But given their small size, this could be done under local anesthesia with or without oral or IV sedation if you were so motivated. While Coolsculpting or Exilis devices would produce some positive changes in the inner thigh bulges, it would not be as much nor as fast as with microcannula liposuction fat extraction. Since these inner thigh bulges have been present your entire life and this body area is not a known fat depot side, the reductive changes induced by liposuction should be permanent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a natural breast augmentation that will last and hopefully not need to be redone repeatedly. Also, I can not support stem cell enriched augmentation if the source of such cells is from aborted babies. Is this the only source? What is being done such as in other countries?  I am also wondering about the possible risk of cancer cells growing from such a procedure. The only info I could find about that seemed to be related to women who had the procedure following a lumpectomy or mastectomy.

Do you recommend the fat transfer procedures? I am not comfortable with the silicone or saline options because of the risks.

I am very small busted and have breast fed many children and now have nearly nothing left.I was small to begin with and now that my last baby is weaned, it is quite different than lactating. Thank you for the information.

A: What you are seeking in natural breast augmentation is the holy grail…natural, permanent, and does not involve an implant. By today’s techniques, you are seeking something that does not yet exist. Natural breast augmentation today uses one’s own fat that is processed and then injected and may have some viable stem cells in it. Besides having to have enough to fat to harvest and use, one has to accept the unpredictability of how much fat will survive and whether it survive smoothly without irregularites. There is also the risk that the procedure may have to be repeated depending upon how much fat survives during the first procedure. What is not known about fat transfer is if it increases the risk of breast cancer although this is believed to not be a concern.

While fat injection breast augmentation is done today and is becoming more mainstream, it is still restricted to a very few women who have the right physical qualifications for it. It is far from a breast augmentation technique that is perfected. For a reliable breast augmentation result that produces an immediate and predictable result, implants a much more reliable technique despite the limitations of being a medical device.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping for a flat spot on the back of the head. My son is twelve and has a noticeable flat on the back of the right side of his head. He has not said anything about it yet. In preparation for the possibility of coming to see you, I have an important question. Does getting kryptonite mean he will never be able to play contact sports such as football again?

A: Skull reshaping that involves building out flat or depressed areas is done by applying a bone cement material on the outer aspect of the skull. In answer to your specific question, kryptonite as a cranial augmentation material is no longer available and has not been so since late 2011. In answer to your general question, augmentation of the occiput (back of the head) would in no way preclude one from participating in form of sporting activity including contact sports. The strength of the cranioplasty material up against the rigid skull bone makes for a very hard construct that has the same strength as that of natural skull bone. This makes it highly impact resistant to the infrequent contact to the head that may occur in most sports.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How can I be a part of the FDA-approved clinical study for stem cell enriched breast augmentation?

A: To the best of my knowledge, there is no current FDA study that is evaluating stem cell enriched breast augmentation. Some plastic surgeons use the term ‘stem cell enriched’ when breast augmentation is done by fat injections, but that is neither part of an FDA sanctioned study nor is it truly stem cell enriched. Since all harvested and processed fat contains stem cells, calling fat injections stem cell enriched is a very liberal use of that term. (more bluntly an exaggeration) True stem cell enrichment would mean that stem cells are isolated and then put back into fat injections in a very concentrated form with high numbers of active cells. That is a quite different process that simple fat harvest and concentration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have double chin surgery. I am just 42 years old and have a roll of what feels like fat under my neck that never goes away. I am actually very slim and this is my only problem area on my entire body.  What treatment is recommended in my case? Thank you.

A: The type of double chin surgery that one needs must take into account four anatomic factors. How much fat is in the double chin? Is the chin short or has inadequate projection? Is the plastyma neck muscle separated or split apart allowing deep fat to protrude through? Is the neck skin loose? This corresponding treatments could include submental/neck liposuction, chin augmentation, a platysmaplasty or a full necklift.

For a patient in their early 40’s who is unlikely to have much loose skin (unless you have lost a lot of weight) the most likely anatomic culprit is fat, making liposuction a primary treatment. If you have a weak chin, a chin implant will significantly help with the liposuction with a diametric benefit to the jawline. (neck goes up, chin comes forward)

If you have a very heavy neck,  a playsmaplasty (tightening the neck though a small incision underneath the chin) will improve the angle of the neck more than liposuction alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a breast augmentation revision. My original breast implamt surgery was about a year ago. I feel like I paid to have big saggy boobs. I wanted a “fake” look and I don’t think my doctor was listening to me. When I lay down they fall to the sides. I have saline implants (500ccs overfilled) under the muscle. I have three kids so they were deflated beforehand and a little saggy. They don’t look horrible now but they are not what I wanted. I waned a very full upper. I think they look natural and I don’t like that. Attached are some pictures of my breasts from today.

A: In breast augmentation revision, it is extremely important to know from where you and where you want to go from here..and then determine if it is realistic and how it might be achieved. You obviously had some significant sagging beforehand so the implants have merely taken what you had and make it bigger…filling out the deflated breast mound. This leaves you with larger breasts that still have some sag and not the upper pole fullness that you want. You have three options for a breast augmentation revision. One is to simply place bigger implants. With indwelling 500ccs implants (let’s say 550 since they are overfilled), it would have to be a minimum of 250cc size increase to be significant and ‘fake’ looking. Even bigger implants will not lift up your breasts higher on your chest wall. This approach just gives you bigger breasts that through a volume increase would provide some greater upper pole fullness. The second option would be to keep your current breast implants and do a lift, putting them higher-up on your chest which would make them look rounder and higher. This will create scars to do so and would be challenging to do with your tight skin and keep your current size implants. Given the current shape and position of your breasts, the prospect of scars on your breasts does not seem justified even though they are somewhat low and still a little saggy. Lastly, you can just aim to keep them from falling to the sides so much.You can tighten the pocket (lateral suture capsule tightening) to keep them from falling to the sides. This would only improve but one problem that you currently see in your breast augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull reshaping. I am a 32 year-old man with an odd-shaped head with a prominent ridge running own the middle. While I could always feel it, it never bothered me until I started to lose my hair. Now I feel like an alien with this visible ridge on my skull. Can it be reduced?

A: Skull reshaping can involve reduction of prominent bony areas or bony buildup of deficiencies. One particular bony skull excess is the sagittal ridge or crest that occurs in the midline of the head. It usually occurs due to a mild anomaly of how the sagittal suture closes after birth. As a result it can develop excessively thickening creating a ridge or crest in the midline of the head that is especially noticeable in men that have short hair or shaved heads.

Because it is a bone protrusion or thickening it can be reduced to a more normal skull contour without risk of exposing the dura or penetrating into the brain. This procedure is done under general anesthesia through an incision placed at the back end of the crest. A scalp flap is elevated exposing the crest that is reduced with the use of a burr creating a smoother upper skull contour. The scalp tissue is closed without use of any drains and only a head dressing is used for the night after surgery after which it can be removed. These small scalp incisions can heal remarkably well.

In summary the sagittal ridge is a midline bone protrusion that can be reduced through a minor skull reshaping procedure using small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana