Your Questions

Q: Dr. Eppley, I am interested in forehead reduction surgery. I have always had a high forehead and I have been embarrassed about it most of my life. I do my bangs everyday cause its all I can do to cover it and I get stares constantly everywhere. I wanna be like a normal person so I can get up out of bed and run out the door without having to do my hair. I don’t even get the mail unless I do my hair. I don’t even wanna go out and play with my kids unless my hair is done. I don’t get in the pool with them because I don’t want to get my hair wet around people. I want to know if I would be a good candidate for a one step procedure because I don’t want my head inflated with a balloon.  Thanks so much!! (sorry my pics are horrible but I can’t do anything with my hair cutting wise or color)

A: Based on the picture you have sent, I can see your concerns about a high and broad forehead. While the picture may be somewhat distorted because of the fisheye lens effect from a cell phone camera, there is no question that you have a high hairline and what appears to be frontal bone bossing. I would need to see a side view that is not so close-up to have a better appreciation for the hairline position and how much true frontal bossing you really have.

You would definitely need a combined frontal bone reduction and frontal hairline (scalp) advancement. The key to whether a single stage procedure would offer enough benefit to make the effort worthwhile depends on how much your scalp can be advanced. That would be a function of how much natural flexibility it has (looseness) and how much it can be mobilized. There is also the question of how much hairline advancement do you need to make a difference and what is the location of your temporal hairline. (which is the most resistant to any significant forward movement. More pictures would help make those issues somewhat more clear.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley,  I am interested in custom facial implants to correct asymmetry and deficiencies from previous corrective jaw surgery. My case is completed in that I have significant nerve damage on the left side and an existing Medpor jaw implant on the same side that doesn’t address the problem.

A: Your description of your mandible/chin concerns is complicated but that is what makes it only treatable by a custom implant approach. Using a 3D CT scan, the shape of the lower jaw can be clearly seen with all of its asymmetries and deficiencies as well as a clear view of the indwelling Medpor implant. An implant can then be designed, most likely as a single piece that wraps around the jawline, after the computer removes the Medpor implant. Surgeries like yours are challenging due to scar tissue and the never easy removal of Medpor but can be very successfully improved with the aid of a custom facial implant approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 20 year old male and am interested in forehead augmentation. I have a protruding occipital bone and a slightly sloped forehead. I would like to get my occipital bone reduced, and then have the bone transferred to my forehead to make it more vertical. I reckon my own bone would be a better and safer material for forehead augmentation than a foreign substance like methylmethacrylate. Is this possible? I have heard wonderful things about your expertise, and I am willing to fly all the way to the United States from Australia to get the procedure done.

A: In regards to forehead augmentation, your concept of transferring bone from the back of your head to the forehead seems logical but unfortunately will not work for many different reasons. There would not be enough bone, it would have the wrong shape and part or all of it would be resorted. The safer, easier and highly predictable option are a variety of synthetic materials that maintain their shape, can be precisely shaped, and will not ever change shape after surgery. Options include PMMA, HA or a custom silicone implant, each either own unique advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in mandibular plate and screw removal. I had a sagittal split mandibular advancement done in 2012 with the use of 4 hole titanium plates and screw on each side of the jaw. Because I am a fairly thin person, I can feel the plates on the side of the jaw and I think they are also making my jawline wider in this area. Bone may have grown on top of them (which I am told is common) or there is a lot of scar tissue around them. Either way they make my face feel fat and I think their removal would have a somewhat thinning effect on my jawline. I went back to my original surgeon and he told me they look fine (weren’t loose) and removing them would be difficult, if not impossible, and wouldn’t make ay difference in how my face would like. Do you agree with him? Could these plates and screws be removed?

A: Your surgeon has the advantage of seeing you and your x-rays so any answer I would give would be based on incomplete information. But what I can tell you is that I have removed many times titanium hardware on the lateral cortex of the mandible in the angle and body area form either orthognathic or trauma surgery. I have yet to see hardware that could not be removed although it is never as easy as ‘just untwisting the screws and removing the plates. Bone overgrowth is common and to be expected. Often a thin film of bone covers the hardware and fills the screw slots. Some screws occasionally may have had their heads stripped while being tightened. You just never know what you are going to get. Burring off the bone from the screws will often destroy the screwheads which can make it very difficult.

One technical aid I have used recently is the Sonopet system for bone cutting and removal. Using high energy sound waves can very effectively remove the bone layer on the plates and screws with less trauma to the metal screw heads. It can also precisely and carefully remove bone from around the plate to get under it.

Whether removing the hardware will make your face thinner is matter of how big the plates are and the bone coverage that they have. But up to 5mms of thickness can be reduced from where the hardware once was. This can help reduce some width along the jawline in that area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In 2010 I had vertical Medpor jaw angle implants implanted. I am not so pleased with the result so therefore I would like to remove them. Is this possible?
Also, I would like to replace them with lateral width jaw angle implants, this is what I wanted in the first place but there was a miscommunication between myself and my previous doctor. If possible, and I know that it differs from case to case, what is the average approx. cost for this procedure? I would be flying in from Eurpoe so I would like to do the consultation and surgery in one trip. I can send pics to help before the consultation. Thanks.

A: I have had the experience of removing numerous Medpor jaw angle implants and replacing them with silicone-based jaw angle implants of various dimensions. Medpor implants can certainly be removed successfully although it is somewhat tedious as the tissues can be very adherent to them. It often can be just as traumatic to the tissues as their initial placement…and sometimes more so. But it can be done without any damage to the bone. Once the implants are out, there is plenty of room (pocket space) for the new silicone lateral width implants. But because silicone is a smooth material and the tissue pocket will be much bigger than the implants, it would he critical to secure the new jaw angle implants in with screw fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been an admirer of your work for some time & consider your website an invaluable resource for patients seeking to inform themselves in regard to cosmetic procedures.

I am a young male in my late twenties. My question relates to cheek implants. Specifically, I am looking to address two issues and I am hoping you might offer me some insight & the benefit of your expertise to provide advice as to what might be suitable choices. I have some asymmetry, my right cheekbone is less pronounced and has less anterior projection than my left side. I prefer the left side. I have also lost some weight & this has contributed to a loss of mid-face volume and deepened nasolabial folds. I do however have fairly good malar projection laterally, especially on my left side.

Would you advise me to address these issues with submalar implants of differing sizes or perhaps a combination implant on one side or both? I wish to avoid feminising my face through excessive lower cheek volume, but I am very keen to mitigate the asymmetry and restore lost volume in the midface. I would like to achieve the classic “v” shape model look if at all possible, but addressing the two issues I described is my priority.
Thank you for your time and attention.

A: In regards to your cheek asymmetry, the issue is whether you should just correct the right side to better match the left or do both sides with differing size and shaped cheek implants. The issue with either approach is how to best obtain symmetry. To do so you have to have a stable target so to speak. It is more predictable with standard preformed implants to just do the right side to try and match the left. But when it comes to implanting both cheeks that are already very different, it is pure guesswork with preformed implants. And such guesswork will undoubtably lead to improved cheek and midface volume but persistent asymmetry of some degree. If you are going to both cheeks, it is probably best to consider custom designed implants to get the best coverage and volume with the best shot at achieving much improved symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. I had a 6-7 mm sliding advancement genio a little over four months ago (no vertical change, just a straightforward Sagittal advancement secured with a single titanium bone plate). From the beginning, I hated it. Even as the swelling has gone down I think it makes me look masculine, old, and like I have gained weight. I regret it so much and cry every day. I know I can’t go on like this but I am worried that reversing the procedure completely will give me jowls, which I never had to begin with. I understand you have some experience with reversing the procedure and I’m wondering if you think I will ever look like I used to. Thanks and please write back as soon as possible, I am becoming extremely depressed.

A: Sliding genioplasty reversal surgery can be successfully done. I have done two such procedures just in the last month. I do not have a picture of what you looked like before to see if you can return to your previous look. But that issue aside, if you put the chin back form whence it came I see no reason why you wouldn’t return to your preop appearance. You are obviously young with good skin elasticity so you should return without a high risk of jowling. The way to hedge that risk of howling in a setback genioplasty is to just go back 4 or 5mms and end up with an overall 1 – 2mm advancement change from the original. There is some reason you had the genioplasty and this may be a good compromise approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding capsule formation that I was hoping you could clarify. I have heard what I believe is misinformation that the material of Medpor facial implants produces a different aesthetic outcome than silicone facial implants in terms of chin/jaw implants . The reasoning this individual used was that silicone implants form a capsule and therefore the appearance of such an implant will always appear “off”, and that Medpor implants will not result in such a capsule.

Correct me if I’m wrong, but I believe that Medpor also forms a scar capsule (albeit a smaller one) and that while silicone forms a capsule, it is not one that has any significant or noticeable aesthetic impact. Capsular contracture can form aesthetic complications, but that is a actually rare complication not common to chin or jaw implants. 

Is my understanding correct? If one were to make a custom silicone implant the exact same size and shape as a Medpor implant, wouldn’t the aesthetic outcome be identical?

I would appreciate any clarification you could provide on this topic.

A: All implants placed in the body produce a surrounding scar, whether it is a facial implant or a breast implant, regardless of the material. This is a natural protective reaction of the body. (self vs non-self) Thus both silicone and Medpor facial implants produce a surrounding scar (capsule) with the only difference being is that the capsule  produced around a Medpor implant will be more adherent or stuck due to the irregular semiporous surface of the implant. The scar capsule will also be slightly thicker as a result.The internal surface of a silicone implant capsule will be very smooth (and thinner) since the implant surface is smooth. But beyond that, the biology and make-up of both implant material’s capsules are similar.

From the outside and its aesthetic results, identically shaped and sizes of Medpor and Silicone facial implants will look the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a consultation with a plastic surgeon last year who had all my personal information prior to the visit. Within two minutes they told me they don’t do any surgeries of any kind on cancer patients who had received radiation. I was upset, mad and disappointed because they knew all my history. Then I was charged $125.00 to be told that. Are plastic surgeons not doing surgeries on cancer patients? I do not need reconstructive work. I only had a lumpectomy but I would like smaller breasts and a lift. Any information would be greatly appreciated.

A: Reconstructive and cosmetic surgery can be done on the irradiated breast but it requires different considerations and surgical approaches. The irradiated breast, which may appear quite normal, is not. Its ability to heal is compromised by the negative effects of radiation on the blood vessels that supply the breast tissue, skin and nipple-areolar complex. A surgical procedure will likely unmask its limited healing ability resulting in incision separation, skin necrosis and partial or complete loss of the nipple.

In reconstruction of the irradiated breast, this well known compromised blood supply is managed by bringing in normal tissue that has a good blood supply through tissue flaps such as the LD, TRAM and DIEP. Such drastic’measures in cosmetic breast surgery, however, are obviously not warranted.

The choice in the irradiated breast patient that wants to undergo a cosmetic procedure like a breast lift is to either take the risk that no such complications will occur or to improve its healing capabilities. Improving the blood supply of the irradiated breast is done by initially doing first stage fat injection therapy. Through liposuction harvest, fat is concentrated and injected through the breasts implanting fat and stem cells. This approach has been well shown to obviate many of the negative effects on the tissues caused by radiation. Three months after the injection therapy, a breast lift/reduction can be more safely done. It may seem counterintuitive to initially make the breasts a little bigger by fat injections but this therapy completely changes the vascularity of the tissues which is essential to heal from any tissue injury.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been perusing through your blog and I’m curious about forehead augmentation. I would like a more masculine brow bone and forehead. I feel like mine is flat. I’ve attached a profile view. Do you think it would be beneficial to my appearance. What I don’t like is my forehead starts to slope back starting from the brows. I would like it to be more square as if a stick was held against the forehead, more of the forehead would touch the stick instead of only the brow bone. From what I gather, the most economical option is using PMMA bone cement, correct?

A:  Forehead augmentation can be done by using either intraoperatively applied PMMA bone cement or a custom forehead implant. The cost differences between PMMA and a custom implant are not really that different. While PMMA bone cement cost less (the material) than a custom implant, most of that material cost savings is offset by the increased time too place and shape the material. A custom implant costs more than the PMMA material to fabricate but is done in half the operative time, with smaller incision and a lower risk of potential revision due to shape. In the end, both forehead augmentation techniques cost about the same.

In the past, PMMA bone cement was the only forehead augmentation option available. But computer design technology is now making custom implant designs not only possible but affordable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the brazilian butt lift. I originally booked the procedure with another doctor. However, he will not be available for the procedure now and he mentioned you as one of the doctors I should see. I am hoping to get the same service as he was providing, which was liposuction of the arms, back, abdomen, flanks and inner thighs with a minimum 1000cc injected into each buttock.

A: I certainly do a fair number of Brazilian Butt Lifts. The key question, however, is whether you have enough fat to harvest that could be filtered and concentrated to be able to inject 1000ccs per buttock. That would be exceptionally unusual. To be able to get 2000cc of injectable fat, you would have to have close to 6,000cc (6 liters) of fat to harvest. That may be possible in you but since I have never seen your body I could not tell if that was so. What most patients don’t understand is that only concentrated fat should be injected not just the liposuction aspirate. Taking the liposuction aspirate and getting rid of the blood, broken fat cells, free lipids and the tumescent solution usually results in a 60% to 70% shrinkage of volume of ‘fat’ that has been harvested. Thus only about 1/3 to 40% of the lipsuction harvest ends up being useable for injection.

For most Brazilian Butt Lift patients, the maximal amount of fat that can be harvested and injected is done as most patients have an overall deficiency of fat for the procedure (based on their goals) rather than an excess. For this reason, I do not promise any patient that a specific amount of fat will be injected as that is an unpredictable number until the fat is harvested. I would have  a good feel for an approximate amount that could be done in looking at one’s body and thus an estimate could be given before surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I’ve had a bad experience with a primary rhinoplasty making my nose too thin, specially in the upper area where my eyes are (T shaped). I believe the cause of this is overly aggressive osteotomies.  I have morphed a picture where I make the upper third of the nose wider (Y shaped). Would you mind telling me if this is possible with a revision?  Thank you for your time. Looking forward to hearing from you.

A: The nasal bones can not be recut and expanded to create that shape in the upper nose. A revision rhinoplasty using outward osteotomies is not stable and will not hold even if they could be cut to make that shape. Widening the nasal bones is hard enough but to make the nose have a T-shape (or return to it) would be impossible by just moving the nasal bones. The only way to create that shape would be by adding a material or graft to the outside of the nasal bone. That could most easily and assuredly be done by making a small custom implant to fit over the radix to create that exact shape using a 3D CT scan. This is a perfectly safe place for a small nasal implant.  It could also be done using graft materials such as cartilage, bone or acelluar dermis but there are shaping/contour concerns with this type of revisional approach and issues of symmetry and smoothness would be a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw surgery two times and now have lip damage. Bottom lip seems paralyzed or damaged. (lower lip asymmetry) I saw online and seems others have had the same problem. I have seen it may be hyperplasia of depressor orbis lip muscle or paralysis of lower lip nerve. I don’t know what it is. Do you think it is nerve damage or muscle damage? Is it likely to be permanent damage after jaw surgery or temporary? I has been one year now and still no change. It is less obvious when relaxed but when make ‘O’ shape with lips or kiss shape with lips or smile it pulls down to one side on my right. The left side doesn’t pull down. I did think it was the right side which shows lower teeth when smile which is the problem side but actually I think after research it is the left side which doesn’t show any teeth when smile which is the problem side. I have seen certain solutions are to use Botox but are there any other options? I want something permanent. Can a surgeon correct it with more invasive surgery? Can they maybe correct the problem side or maybe damage the other side so both don’t show lower teeth when smile because personally I think that looks better to only show upper teeth. I really need your help doctor. Please help thanks.

A: What you have is paralysis of the left marginal mandibular branch of the facial nerve. This tiny nerve branch supplies movement to the depressor muscle of the lower lip. With the nerve being paralyzed that side of the lip does not move down normally while the opposite right side does. With no lower lip movement on the left, the normal righth lower lip retraction looks exaggerated and overly pulled down. This lower lip appearance can make one think the side of the lip that moves is the problem when in fact the th higher lower lip side is the culprit of the lower lip asymmetry.

At one year from the injury with no movement, there is no reason for optimism that the paralyzed nerve will start working again. I wouldn’t say it is impossible but very unlikely. There is no method to make the nerve work again other than natural healing. Thus the treatment for lower lip asymmetry from  permanent marginal mandibular nerve paralysis is to weaken the opposite side whose muscular movements are exaggerated. This can be done by Botox injections (temporary) or by partial resection of the depressor muscle from an intraoral approach. (permanent)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get cheek implants soon. I am also interested in having a hair transplant about 6 months after I have cheek implant surgery. My question to you is do you think it is safe to have a hair transplant after cheek implants? …. Is there any risk of infection to my cheeks implants? … during the hair transplant they will poke the front of my hairline hundreds of times. Can this in any way effect my cheek implants ??

A: This is a thoughtful question that speaks to the potential of bacterial seeding of any implant in the body due to bacteremia (release of bacteria in the bloodstream) after any invasive procedure. I think as long as your cheek implants are well healed and have an intact mature capsule, this potential risk is very low to negligible. It can easily be compared to having a dental cleaning in which one has any implant in their body. This is clearly not a problem of any magnitude given the millions of people who get their teeth cleaned or undergo any dental work and have surgical implants of many varieties and anatomic locations. But to be safe, and this would be done anyway, take an antibiotic starting one hour before the surgery and then for a few days after.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had chin implant replacement done 3 months ago. I had a Medpor chin implant replaced by a silicone square chin implant as I wanted more squareness to my chin and wanted it wider. Today is officially 3 months after surgery and it’s been frustrating for me. Two sides of my chin where the previous wing were removed are still presenting irregularity and swelling. When I touch it it feels kinda soft and tissue like. I’m not sure it’s the capsule or scar tissue still remaining there. It makes the two side of chin still look like swollen and the jawline is not straight at all. But it is definitey improved since the first month after surgery .I’m just really anxious about it everyday now and I’m wondering when will it fully healed? I have searched online and some people says steroid injection can be done. Should I do that? I’m pretty sure the implant placement itself is fine but the capsule or scar tissue is making it look bad. I hope you can help me 🙂

A: Full and complete healing after any facial skeletal surgery can take up to 6 to 12 months after surgery to see and feel the final result. This can certainly be true for revisional chin implant surgery where one iimplant (that is well scarred in) is replaced by another chin implant. The important question is whether the fullness that you see is do to scar tissue/healing or that the implant is simply too wide/big. If it feels soft and tissue like then I would say there is still healing going on and more time would be the appropriate answer. I would not advise steroids as that is an uncontrolled drug treatment that can have adverse soft tissue effects (atrophy and indentations) and thus it can create just as many problems as it may solve. The only injectable treatment to consider is 5-FU injections which can help settle scar tissue but has no soft tissue atrophy effects. Otherwise, if the sides of the chin feel hard, then this is an implant issue where it may be too big or wide

The steps to take now are either 5-FU injections and/or continue to give it more time. At the minimum I would give it at least six months from the last surgery before contemplating anything invasive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently spoke to you regarding jaw implants. I am still in the process of getting custom jaw implants done, however, I’ve decided with my surgery I would also like to get temporal implants. I read your notes (very helpful) on this surgery and I want to know if temporal implants for men will achieve a square top half of the head… similar to how jaw implants make the bottom half of the face more square. After having jaw and cheek implants I’ve noticed that my temples look sunken in and my face doesn’t look normal when my hair is brushed back. I guess Im wanting to know that the goals I’m wanting are achievable with this implant. I also find that I can’t wear short male hair styles that can make the face look square and masculine because my temples sink in a bit. 

A: The answer to your question is all in how the implants are designed and at what tissue level they are placed. Traditional preformed temporal implants go into the hollows between the hairline and the eyes under the fascia and on top of the muscle. I get the impression that your temporal concerns are more towards the mid-temporal area back in the hairline and upwards toward the top of the head where it transitions into the horizontal skull plane. Augmentation of this area requires custom implants that need to be placed above the fascia in the ear area that extends upward to the temporal line to create that effect.

I would, however, really need to see some pictures of your temporal concerns to provide a more qualified answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a very very thin Asian male that is looking for buttocks enhancement to get more of a Hispanic or Afro looking buttocks that is more perky and with a lot of volume. Because I am thin I know that fat grafting is obviously not an option so from what I know, implants are my best bet. I am looking for more of a shelf with augmentation in the upper buttocks area but as well as more outward projection to the entire thing…protrusion up and out. I would like to go for bigger implants if possible (that are within reason). I do a lot of physical activity such as dancing, running, biking, you name it. From my understanding placement can be from most superficial to deepest, subcutaneous, subfascia, intragluteus maximus or under the gluteus maximus. I have heard that intramuscular is best for augmentation towards the top but for more actual outwards projection, subfascia is better because the space is larger and because intramuscular would make it close to the sacral nerve which is dangerous. My questions therefore are as follows:

What would you agree is the best placement for somebody of my build with my goals? 

I understand that this is based on softness of the implant, but why would anybody want to have a harder implant over a softer one?

Because I’m trying to aim for more of as a shelf as well as projection additionally, is it possible I might need different implants placed in different spots?

What would be the max size you would put in somebody of my thin male Asian build?

What kind of buttock implant shape is best?

A: Thank you for your thoughtful inquiry and insightfiul questions. A male getting buttock implants is uncommon but certainly not unheard of. There is no question that the best long-term results for buttock implants is in the intramuscular position. (never completely submuscular as this is where the sciatic nerve lives) This follows a general rule that the deeper an implant is placed and the more well vascularized soft tissue cover is over it, the better it is for the implant and the fewer complications that can ensue. But when looking at your aesthetic goals, an intramuscular implant can not achieve the buttock size and projection that you seek. Thus, only a subfascial implant placement will work. This will allow for a larger buttock implant size and it will have more lateral and posterior projection. A round shaped buttock implant is what you want to use. (oval implant can rotate in the subfascial plane which can create an obvious problem)

It is hard to know without seeing you and taking measurements as to the maximum implant size that you should get. But certainly I would not think bigger than 450cc to 500cc

Buttock implants are made of a very soft gel elastomer which feels very much like muscle. There is no reason to use a harder implant durometer.

You never want to place more than one implant for any body area, the buttock region notwithstanding.

A primary concern in any buttock implant patient is that they take teh required time to allow the tissues to properly encapsulate the implant befire beginning any strenuous activities. It would be well advised to wait at least four to six weeks before doing so. Seroma formation is the number one complication in buttock implants and a primary cause is too early physical activity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wearing braces and the distance between my upper lip and nose is short maybe 1.2 cm now. But I know that if I take off the braces the distance will increase to 1.4 or 1.5cm. I don’t want to do lip augmentation. I want the lip lifting procedure and I want to do it wearing braces. Is that possible?

A: Having orthodontics appliances in place does not impede the ability to do a subnasal lip lift. The question is whether one can tell how much to remove so as not to end up with an overdone result. Subnasal lip lifts that have had too much skin removed have no recoverable strategy…you can’t put back the skin that was removed without a very visible graft under the nose. If your calculations are correct you would do a 3mm skin resection for your subnasal lip lift. If you have do do the lip lift before your braces are removed just make sure it is a conservative amount of skin removed. Removing your braces ma result in the lip lengthenng a few millimeters. But since you have not done that test (remove your braces and measure it), assume that maybe no change in lip length will occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: D. Eppley, I am contacting you because you are the only surgeon I found that discusses Medpor implants extensively on your blog. I had a rhinoplasty with a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left and the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty. He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”.  

I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage). I have what appears to me to be pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball away from my bridge. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose with a ball of tissue projected by the implant in my columella. The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed rhinoplasty.

Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all.

A: While I have not examined your nose, the question for your revision rhinoplasty is what is the source of the tip problem and what is the best way to solve it. Between the implant and the scar, it is hard to know the bigger source of the problem but in my opinion but need to go. This is best accomplished with an open rhinoplasty with replacement of the implant with a septal cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgical scar revision for my box car acne scar. I have undergone microdermabrasion, fractional laser resurfacing, and TCA peel to the area but none of them have had any beneficial effect. It seems like something deeper will need to be done or perhaps just cutting it out. I don’t know as I am not a doctor but none of these other doctors seems to know either.

A:  As you have discovered, none of these superficial treatments are going to work for your type of facial acne scar. This is a problem of tissue atrophy/loss not one of just a more simple surface contour irregularity. Your acne scar surgery options include either excision and geometric scar rearrangement or scar adhesion release and injectable fat grafting. You can first test out how well fat grafting may work by having some injectable filler or even a trial of saline injections done to see if the scarred area will lift up by adding volume by injection underneath it.

Give its size, total excision and a geometric closure is also a consideration. What needs to consider how much tolerance one has for the healing and maturity of a scar on one’s face vs. whether one wants to first try an injection approach before embarking on a ‘bolder’ excisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a subnasal lip lift which I am pleased with the lift in the center of my lips. Now however, it seems to accent the thin corner of my liplips. Aesthetically to balance out the look, I think this is something that should have been done too. Can a corner lip lift be done with local anesthesia?

A: The subnasal lip lift in the right patient is a very effective lip augmentation procedure but it will only affect what lies within the skin excision pattern. By dropping down a vertical line from the sides of the nose to the lip, the lip area improved will only lie within. In essence, it shortens the amount of vertical skin between the base of the nose and the upper lip and only provides accentuation of the cupid’s bow of the upper lip. It would not be rare to a have a lip lift patient turn their focus to the sides of the lip and the mouth corners thereafter.

The key question about changing what was not improved by the lip lift is defining the exact area of outer lip deficiency. This could be either an isolated corner of the mouth lift or an extended corner of the mouth lift that extends further up along the sides of tails of the upper lip. This distinction is critical to understand. An isolated corner of the mouth lift will just change the angle of the corner of the mouth and will not make it thicker. A extended corner of the mouth lift or an outer lip advancement will make the sides of the lip fuller.

I would need to see a picture of your lip to help you decide what is the correct lip augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in a pinch lower blepharoplasty and am seeing if I am a candidate for the procedure. I took the picture smiling because the wrinkles aren’t as noticeable when I’m not smiling. I have seen a few plastic surgeons about my options. I do have a little fat under my eyes that I’ve been told could be fixed by filler or moving the fat around. That doesn’t bother me as much as the loose skin, and I’m hoping that tightening the skin will help. I will be fifty in November, but I lead a very healthy lifestyle with regular chemical peels.  If I did the recommended procedures, what is the recovery time?

A: The difference between someone who needs a pinch lower blepharoplasty technique versus a full lower blepharoplasty is a function of numerous factors. How much loose skin is present, is there an orbicularis muscle roll, presence of any fat herniation and how much loose wrinkled skin do they have. In addition, the age of the patient and how much facial aging they have is also relevant…as pinch blepharoplasties are generally reserved for early signs of periorbital aging. (less than 50 years of age) Your picture is a smiling one so that obscures some of this anatomic information. But clearly you are young and do not have much herniated fat. Thus based on this one picture, I would say that a pinch blepharoplasty combined with a 35% TCA peel for the rest of the lower eyelids and 8 units of Botox for the orbicularis muscle activity per eye would be beneficial. You can’t get rid of all your lower eyelid wrinkles with any procedure, particularly when one smiles, but this would provide a major improvement with limited downtime. Expect one week or less of a ‘cosmetic’ recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need help in determining what type of revision rhinoplasty I need. I had a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left (especially in the tip) than on the right side; the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft/overlay graft in the dorsum. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty (referred to it as a septorhinoplasty). He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”. 

I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage (not excess). I have what appears to me to be a pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball someplace away from my bridge, underneath where the tip used to be before it “dropped” filled out due to injury or naturally, like a tube. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose, with a ball of tissue where the nose used to simply droop down flat. That “ball” is projected by the implant in my columella. 

The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed septorhinoplasty.

Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all, will have a period at least as stressful, and will cause the same problems in the tip. 

A: The short answer to your revision rhinoplasty dilemma is…have an open rhinoplasty and get the Medpor implant out and replaced with your own cartilage if it is still needed. This is the only to ensure that you can get the best result long-term. A synthetic implant in the tip of the nose may or may not be part of the problem…but I doubt it will be part of the cure. With scar tissue in a revisional nasal tip surgery, visualization and removal of all scar tissue with cartilage reconstruction is the only way to successfully reshape the bulbous and overprojected nasal tip consistently.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my one month old son has cleft lip and palate on the left side. It is due to be repaired in another few months. Besides the cleft lip, the nose is also very distorted and wide set. Can his nose also be corrected at the same time as that of his cleft lip repair?

A: The initial cleft lip repair is usually done around the age of three or four months after birth. During a primary cleft lip repair, efforts are always made to reshape the distorted nostril and tip of the nose. Some of the nose improvements are natural as the lateral lip element is one and the same with the base of the nostril. So the base of the nostril naturally gets better as the two sides of the lips are brought together and united. But one should not think of this nose effort as a definitive rhinoplasyt or a complete correction. The lower alar cartilages of the nose are still deformed and remain small in development. They are far from completely formed and these initial nasal correction efforts at the time of the cleft lip repair are mainly to improve the width of the nostril base. The nose must undergo further development and additional nasal work will be needed during the early school  and teenage years to more extensively reshape the deformed tip cartilages and correct septal deviations and other nasal abnormalities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation using malar shell implants but I have not yet had the procedure because of certain concerns. I am concerned about the submalar fullness which I had noticed in photos of female patients who have had the submalar cheek implants placed. Although I definitely have the concavities in the submalar area which would benefit from some augmentation, I did not want “apple” or “cherub” cheeks. (Check out Barry Manilow’s face now). This type of fullness can look artificial and certainly looks better on females than males. I know that the implant can be modified by removing some projection from the underneath side of the submalar portion of the implant.  Of course, a lot would depend upon how much fullness is already present in the submalar area. I am also unsure of whether the implant would make my face look wider and somewhat “chubby” rather than more sculpted (more attractive on males).  I have a round face lacking in strong structural features. But I was not so sure about what the midface augmentation would accomplish .  In addition, the lower eyelid area concerned me.  Actually, I thought that if the midface implant were placed high on the bone close to the orbital rim, it  would have the nice collateral benefit of minimizing the tear trough area, but I did not know how much an improvement this would be, given the design of the implant. 

A: In looking at your face and all the current styles of performed midface implants, none would be appropriate for what you are looking for. You are correct in assuming that your face would get wider  and would dimensionally change you in the wrong direction. What you need is more anterior or forward projection across the orbital rims and down onto the face of the maxilla. This is actually the ‘missing’ zone of facial augmentation in regards to current implant designs because it is concave facial area and not a convex one.

What you really need is an orbito-maxillary facial implant that improves midface projection but not malar width. This can only be properly designed through a custom implant approach based on a 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in numerous body contouring procedures since I have lost 130 lbs. But I did not achieve this weight by bariatric surgery so would it be possible for me to have multiple procedures in one day? I have a lot of loose skin from my arms to my thighs so I need a lot of work done and the quicker I can get it off the better.

A: The origin of one’s weight loss has little impact on how any number of body contouring procedures are done in a single operative event. Actually extreme amounts of weight loss achieved by non-bariatric means, diet and exercise, are ‘safer’ since there are no metabolic issues to consider. (unlike a gastric bypass) There really are few differences between body contouring after weight loss and bariatric plastic surgery considerations when it comes to the type of body reshaping procedures considered and how they are put together. The key issues in doing multiple  body contouring procedures is the length of time to do the surgery and what period of recovery time does the patient have. As all body contouring involves considerable trauma to the body if you just consider the size of the body surface areas being treated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a wide chin and am interested in a chin narrowing procedure. What is the best way to make the chin bone more narrow? 

A: The benefits of chin narrowing is very clear as you do have a boxy square chin. To obtain substantial chin narrowing there are two basic techniques, bony genioplasty wedge (sliding genioplasty with central wedge reduction) and lateral tubercle ostectomies. (cut off the corners without down fracturing the chin) There are advantages and disadvantages of each method of chin narrowing. Having done them both numerous times, they both can work but there are subtle differences between them that can carry aesthetic consequences. The advantage of the bony genioplasty wedge reduction method is that it does not strip off all the attached soft tissues so the risk of the soft tissues not adequately reattaching afterwards is minimized but it is a ‘bigger’ operation due to the need to down fracture the bone  and the bone cuts come closer to the exit of the mental nerve from the bone. (risk of numbness) The lateral tubercle ostectomy method merely cuts off the corner of the boxy chin and does not need to down fracture the chin bone and thus there is no need for plates and screws to put it back together.  Its bone cuts stay further from the mental nerve so the risk of lip numbness is less. Its disadvantage is that it may not produce as significant a chin narrowing effect and detaches more of the soft tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been opening your website and reading your articles for a while. I think your website is very informative. I would like to thank you for creating this website. Without any doubt i can say your are one of the world’s best and most skilled plastic surgeons. I wish I was very wealthy, I would have flown to USA and set an appointment with you, but unfortunately I don’t have a strong budget at the moment. I intend to travel locally for a chin osteotomy or implant and jaw angle implant. I want to make my face look very masculine and angular. I am attaching my photo to have your viewpoint about the type of jaw angle implant. I want to do something permanent and long lasting. I think my jaw needs a thick implant but I don’t know which shape and type is better. Thanks in advance.

A: While most commercially available silicone jaw angle implants provide only width, the vast majority of men who seek a stronger and more defined jawline need vertical lengthening of the jaw angles as well. Thus a more masculine jawline usually needs a combined vertical and width dimensional change to have a more pronounced flare to their jaw angles. Your pictures certainly show that to be true. The only question is how much vertical and horizontal thickness in millimeters would look best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been self conscious about my deficient chin my whole life. If I so much as look down, I develop a double chin despite being 5’7″ and weighing only 114 pounds. I used to diet often thinking that this would decrease the roundness/fullness of my face but it wasn’t until recently that I realized it is really the lower 1/3 of my face and its overall deficiency that is causing my face to look round and short.

As you can see, I have a very horizontally as well as vertically short chin. The reason I would like the sliding genioplasty vs. a chin implant is to add vertical length to my face as I feel its shortness makes me look younger than I am and also meek/shy which decreases my confidence in my daily interactions with others.

I’ve done the research on sliding genioplasty vs. chin implant, and one of the questions I have is: If I would like a little extra width added to my actual chin (You can tell in the pictures, especially the one head-on picture, that it is not only short vertically and horizontally, but it is narrow), I have read that only an implant can widen at this area, and that a genioplasty by nature of cutting the bone and advancing it will actually serve to further decrease the width of the chin. Is this true? I would like to decrease the odds of this happening if at all, although perhaps adding width to the chin would not even be as beneficial as I think given my facial size in general and would throw everything out of line aesthetically?

In addition, I have read that only a sliding genioplasty can add vertical height to the chin in addition to horizontal projection, but in other more recent publications I have read that there are new implants manufactured now that can be tailored to the patient and add vertical height as well. Would this be an option for me as it is more cost effective or is sliding genioplasty exclusively the way to go given my individual anatomy?

I am anxious to hear back from you, and thank you so much for taking the time to review my pictures!

A: Many of your perceptions about chin augmentation surgery are correct as it relates to the differences between a sliding genioplasty and a chin implant. Historically, it was true that only a sliding genioplasty could add vertical length to the chin but that is no longer true. There are new performed vertically lengthening chin implants (actually they move the chin position out at a 45 degree angle thus adding both length, projection and width) and custom implants can be made from the patient’s 3D CT for any amount of differing chin dimensional changes.

While a one-piece sliding genioplasty particularly if it adds vertical length can make the chin more narrow, that can be solved by modifying the bone  That can be managed by doing a midline split/expansion genioplasty technique and widening the bone as it comes forward and down.

As you can see there are a number of ways to accomplish what you are after for our chin. But the first place to start is to precisely determine what exact chin dimensional changes you need. I will have to do some computer imaging but my initial guess is that about 5mms forward and 5mms vertically longer would be about right. I doubt if your chin should be made any wider as you want to get away from a round and short look and even a slightly more narrow chin in and of itself makes the face look longer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a lot of deep saucer-shaped scars and indentations on my face. I recently read about the use of GalaFLEX and would like to know if this product could be used to smooth out the appearance my face. I once had a doctor in California who suggested using sheets of a “derma” product to place between the skin and the underlying tissue to smooth it out.  When I read about GalaFLEX it appears to be the same type of product. Perhaps you can give me your thoughts on it.

A: The concept of an interpositional material between the skin and the underlying fat/SMAS is an interesting one. As of today there are over a dozen allogeneic and synthetic matrixes/scaffolds that are currently available for use. So this concept is not new and Galaflex just represents one of the synthetic options to consider. All of these have been developed primarily to support the lower pole of the breast in breast reconstruction and in treating bottoming out of the breast in aesthetic breast augmentations. Of the synthetic options, the one I would consider is SERI Silk mesh as opposed to Galaflex since it is currently FDA-approved while Galaflex remains under FDA clinical trials.

Moving beyond the materials, the real question is whether placing an interpositional material under the skin would help smooth out the face. That part is unknown since this is not what it has been studied for and I have know of no patients who has been so treated for that facial skin problem with this method. But I guess there is always a first time in the right patient.

Dr. Barry Eppley

Indianapolis, Indiana