Your Questions

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

Q: Dr. Eppley, I am interested in getting pectoral implants to make my chest bigger. My two very important questions are does the implants distort upon muscle contraction when placed under the muscles? And to create the “pocket” for the implant you need to detach the muscle from the sternum right? Thanks for getting back to me.

A: While there are some similarities between pectoral implants and breast implants, there are difference between them that are more just that one is for men and the other is for women. The implants themselves are different with pectoral implants being a soft but solid silicone elastomer while breast implants are filled with non-solid fillers inside a thin flexible silicone elastomer bag. As such, breast implants can fail and need to be replaced while pectoral implants can not fail and never need to be replaced.

Pectoral implants are put in through an incision in the armpit (just like some breast implants are) and are placed in a completely submuscular pocket. Conversely, breast implants are placed in a partial submuscular pocket often referred to as a dual plane location (part under the muscle and part out of the muscle. When you think of implant distortion with muscle contraction you are thinking of breast implants where half of the implant is not under the muscle and thus distorts when the muscle pushes down on it, causing the implant to move to the side and causing some degree of implant distortion/movement. Neither in breast or pectoral implants is the muscle detached from the sternum at either its origin or insertion. The pockets are created by entering a tissue plane underneath the pectoralis major muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping of the back of my head. I am 45 years and I have a small spot of protruded ridged edge at the back of my head from birth. I have never been comfortable with it and I wish it could be corrected for a normal round shape back head. I wish to know if/how it could be corrected. If possible, what’s the cost implication and how the duration of the treatment and possible medical implications if any. I have attached some photos for your examination and prompt response, I may send you more pictures if you so request. Thanks.

A: Your head problem could be solved by a minor skull reshaping procedure. Your ‘spot’ or bump of bone on the back of your head is a raised area over your original posterior fontanelle area that you had an an infant. This is a common area of minor skull contour deformities from indentations to raised ridges. Your midline occipital ridge can be reduced by a burring technique through a small incision. This is a one hour procedure done under general anesthesia as an outpatient procedure. There are no medical implications by taking a small amount of the outer cranial table. Other than some temporary swelling and small fine line scar from the incision there are no potential complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in extra large breast augmentation. (technically extra large breast implant replacement. Can we do a consultation via email since I live far away. I want 1000cc implants. I currently have 500cc on right breast and 400cc on left and clearly they are not even close to being as big as I asked for. The dr was more concerned about doing what he thought looked best and not accommodating what I wanted at all. It is humiliating as they look awful. This is not remotely the size I was looking to get.

A: The concept of extra large breast augmentation is controversial amongst plastic surgeons. There is a large group of plastic surgeons who choose breast implants based on their assessment of the breast tissues to support them over the long-term. With this concept they do not put sizes that are wider than the patient’s natural breast base diameter or the less measurable quality of the support of the overlying breast tissue/skin sleeve. For many patients this means that sizes less than 400ccs are placed. There is another group of plastic surgeons, arguably smaller, that provide any breast implant size that the patient wants including very large sizes. These implant sizes do irreversibly stretch out the breast tissues and are more prone to bottoming out over time (loss of support) but do meet the patient’s expectations.

What your initial breast augmentation result was less than you wanted, your plastic surgeon probably placed implants that he felt comfortable could be adequately supported by your breast tissues. He or she was looking out for some long-term issues that most patients are understandably not aware of.  This may have been too conservative for you but was a safe approach. The good news is that this is an improveable problem, albeit with another surgery, and larger implants can be placed. You also have the advantage of now knowing what implant size may be acceptable since you know what size change has occurred with the volume you now have in. It is now about volume ratios. If you want a breast size that is twice as big as you now have, you will need a 100% increase in the implant’s volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in learning more about the forehead reduction (hairline lowering) surgery. I genetically have a very high forehead that I’ve always been very self-conscious about. I’m just now learning this surgery exists! I live out of state, so I can’t easily come in for a consultation. How do you handle out of town patients for consults? Can you just use the photos? With that, I’d also like to know the approximate cost of this surgery (or can you estimate based off pictures?). I would appreciate any information you can provide, and please let me know what other information I can provide to you. At this time, email is the best way to contact me. Thank you, and looking forward to hearing back from you!

A: Forehead reduction surgery can be beneficial for those women that have a long forehead,  which almost measures greater than 6.5 cms from the eyebrow to the hairline. Vertical forehead reduction is a skin operation where forehead skin is removed along the hairline and the scalp is advanced in its place. This requires an incision along the frontal hairline and is very much like a reverse pretrichial browlift. The success of the procedure is primarily based on how much natural looseness the scalp has and how much can be surgically created. It is this looseness that allows the scalp to be brought forward. Generally about 10 to 15 mms can be gain in most patients. If the scalp is very tight or the amount of scalp advancement needed exceeds 15mms, then a first stage scalp tissue expander needs to be placed. You can determine how much scalp advancement is needed by taking a mascara pen or lip liner and drawing a line where you want the new frontal hairline and measuring it. Also remember that the greatest amount of scalp advancement is in the middle and becomes less so as it tapers to the sides into the temporal scalp.

We have many far away patients and further discussions can be done by phone or a Skype video consultation. It is not necessary to come in for a separate in-office consultation. The cost of the surgery is very similar to a pretrichial browlift, as I have mentioned, and my office will pass along the cost to you in a separate e-mail in the next few days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reduction surgery. I serve in the military and I really want this forehead reduction done. I hate my forehead. It is wide with a high hairline and my forehead protrudes. Please help me! I would love to do the military program but this procedure is not on the list.  Attached are some photos which shows how high my hairline is and how my forehead bulges out.

A: While you would be a good candidate for a forehead reduction or scalp hairline advancement, it appears you would need almost a 2 cm advancement given the length of your forehead. This means a first stage scalp tissue expander is placed to create more hair-bearing scalp that then can be used and advanced to create a really significant forehead reduction as a second procedure. Without a tissue expander or a two-stage approach, the most hairline advancement that can usually be obtained is around 1 cm. While forehead bone reshaping would be also be done, the forehead always seems to stick out more when the hairline is way high and the upper forehead is sloped backwards. Even a hairline advancement procedure alone make a prominent forehead look less protruding because its total vertical length becomes less.

The Patriot Plastic Surgery program applies to all elective aesthetic plastic surgery procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a chin augmentation surgery. I have attached a couple of photos in order to get your opinion. You had written that there is a permanent chin augmentation solution where the implants are secured by small titanium screws. Would those screws need to be replaced after ten or more years? Do they set off metal detectors? It seems that screwing the implant in makes more sense. As my chief concern is the security of the implant and its ability to withstand an occasional stiff impact. I do know some chin implants are used without screws. What is your opinion on those types? My feeling was that since they are just placed on top of the chin and not secured with anything the likelihood for them to become dislodged increases. Not sure if that is true though. Assuming that there are different types of chin implants, (some more square, some more rounded) perhaps when you see the attached photos you’ll have a better idea which one would benefit me the most. Finally, I would be remised if I did not say that being your office is in Indianapolis it seems difficult that I would fly from another state for such a procedure. The logistics alone would be difficult to for me to work around. Though being your reputation is excellent, nothing is completely out of bounds. Thanks for your time, it is very much appreciated.

A: Your photos demonstrate that you would be an excellent candidate for chin augmentation. Your chin deficiency, compared to many patients that I treat is relatively mild, but I would agree that more chin projection and a more square chin appearance would have some aesthetic benefits for you. I will do some computer imaging of that and send it to you later today.

In answer to your questions about chin implants and screw fixation, this is a technique that I have always done in the vast majority of chin implants. It is simple, quick and inexpensive to do and assures that for the lifetime of the patient the chin implant is never going to move or become dislodged. I have certainly never seen it in the 25 yeasrs that I have been doing the procedure. The screws are composed of titanium, a pure element that never degrades or corrodes or needs to be replaced. It is a non-ferromagnetic metal, which means it does not set off metal detectors nor affects MRI scans. While placing screws is not standard practice for most surgeons that place any type of facial implants, it really should be.

While being a far away patient may seem unusual, it is standard in my practice as patients fly in from all over the world every week for surgery. It is easier to do than you think and handling the logistics of how to do it efficiently is a common occurrence for my staff and surgery center.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m undergoing a breast augmentation in less than a week and I like the look of your case study, breast augmentation in Asian women.  I am exactly her size except a smaller breast base  diameter (10.5). For reference, what profile is the implant you used?  I would appreciate any info you could give me. Choosing between 260 high profile, 280 high profile, or 320 full profile (leaning toward 280).

A: Many patients get hung up when considering their breast augmentation of an implant’s profile which actually has little to no influence on the final breast shape, contrary to popular perception. The only real relevance to an implant’s profile is how it influences the base diameter with the goal of using an implant whose base diameter is no larger than one’s natural breast base width. This is the real role of high projection/profiled implants, keeping the desired volume in a very narrow chest to within the breast dimensions. Almost assuredly with a breast base diameter of only 10.5 cms, any implant volume over 225cc will need a high profile implant to accomplish that important aesthetic goal.

Not to confuse you further, as the implant manufactures do a good job of that in this regard anyway, there is no correlation between any of three manufacturer’s (Allergan, Mentor and Sientra) implants in regards to volume and their profile types.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Liposuction of the Dorsocervical fat accumulation.  I am curious if you do this procedure and what ball park of cost would this procedure be in. Please advise as I need your help. 

A: Liposuction is an excellent option and often preferred treatment for neck fat. I believe when you refer to the dorsocervical fat accumulation, you seek the classic ‘Buffalo Hump’ reduction. This is a procedure that I have done numerous times (most commonly in the HIV patient although not always) and I have found that the use of laser liposuction (Smartlipo) can give a very effective reduction without the need for an open operation with a long incision. This is a procedure that takes less than an hour to do, often under sedation or general anesthesia. (it is helpful to have the patient have a good anesthetic depth so the liposuction procedure can be aggressive) Buffalo humps consist of a very fibrous type of fat (often looking more white than yellow) as opposed to a softer and more buttery type of fat more commonly seen in many areas of the body including the anterior neck. This is why laser liposuction or power-assisted liposuction (PAL) is used as it is more effective at breaking up this more dense fat that is held together by fibrous tissue bands. Buffalo humps can be very effectively reduced by this liposuction approach. In my experience, patients have not reported a recurrence of this posterior neck fat accumulation. The ballpark cost would be in the $4,000 to $4,500 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been trying to get an abdominal panniculectomy since I lost so much weight. My insurance company denied me but I plan to appeal. I have infections and skin ulcers. It makes it hard to do my job. I heard about the Patriot Plastic Surgery Program and wondered if you can help. PLEASE!!! I wanted to get this done before my husband got home from his latest deployment and I was wanting to get this done before he got home and I’ve run into roadblock after roadblock. Can you help? I have attached some pictures of my abdominal problem.

A: While there is little doubt that you would benefit from an abdominal panniculectomy, I am not surprised that you have been denied by your insurance company. By insurance requirements you do not meet the very basic criteria of the size of the pannus, it must reach down and overlap onto the thighs. Plus there must be a 6 month history of medically documented skin infections that have failed to respond to topical therapies and there must also be current photographic evidence of active skin infections. Failure to meet all of these criteria will result in denial of coverage for an abdominal panniculectomy. This is a very common occurrence and can be difficult to appeal without providing documentation of their established criteria.

The Patriot Plastic Surgery program is where some reduction in fees is offered for a variety of cosmetic surgery procedures, including tummy tuck and abdominal panniculectomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if scar revision can help? I have had this one inch long scar in my eyebrow frown line since I was a toddler. Because of its location it is starting to become more noticeable as I approach 30. I have tried Botox, SmartXide laser, TCA Chemical Peels, and Sciton LaserPeel and not been that satisfied with the results. I was wondering if you thought it could be improved with a revision or dermal filler or if you think it should just be left alone. The indentation is my primary concern vs. the white line color. Looking forward to hearing from you!

A: Given the effort that you have made to improve your forehead scar, it is reasonable to consider surgical scar revision at this point.That scar is perfectly oriented in exactly where vertical glabellar wrinkles develop. That is why it has been getting more noticeable as you age because it probably is deepening slightly with repeated expressive motions. I am not surprised that none of the treatments you have had were successful as the depth of the ‘crease’ is beyond what they can level out. You are correct in assuming that scar revision would be the only successful approach. An injectable filler will lift up the depression as the skin edges are tethered down. A small geometric broken line closure scar revision would both release the scar contracture, elevate the scar and rearrange the skin edges by interdigitation to prevent recurrence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a breast reduction done but I would like to know if I can breast feed later on when I decide to have children. I am 25 years old, size 38DD, with a height of 4′ 11”. I have been having a lot of back pains,shoulders, and even neck pain as well. This is why I am interested in breast reduction.

A: Breast reduction is a commonly performed procedure that is frequently done in young women who have not yet had children. Even though it is a breast procedure that involves the glandular tissue, it does not interfere with the ability to breast feed. Many women have had breast reduction that have gone on to have children and were able to breast feed successfully. This is because the nipple-areolar complex and its attached ductal tissue remains intact to the central glandular breast mound which is not disrupted from its vascular attachments to the pectoralis fascia/muscle. Thus breast milk can be made and delivered through the uninterrupted and unscarred ducts out through the nipples. The incisions that one sees on the breast mound after a breast reduction have no connection to the breast lactation system.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i am interested in nano fat grafting.  I have heard that fat is beneficial to scar contracture but also I am aware that fat won’t survive in a scar bed and I could wind up with lumps. That is why I thought that the nanofat probably won’t do any harm and may even help. The side of my nose that has a depression or drop off angle is the area with the scar tissue build up. The tissue is parchment thin there. I would like to fill this area with an autologous material. I had surgery  3 years ago to revise a rib graft  done nearly 6 years ago which left me with unatural harsh drop offs on either side of my bridge. I already had restylane done last year and it lumped up on me and caused too much pressure in my nose. I have also been considering trying belotero filler, Would you have any suggestions?

A: While I think nano fat grafting would not hurt, I don’t think it will produce any positive benefits in terms of filling in skin depressions or rib graft step off areas. This all would be better served to be filled with alloderm (allogeneic) dermal grafts.

There is a difference between scar tissue build-up (contracture) and trying to make the skin thicker or fill in contour depression areas. If the rib graft not has sharp edges or visible stepoffs,, adding a layer of alloderm or been temporalis fascia would be the more assured way of improving the soft tissue cover.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty to permanently build up my radix. I had some fillers placed in my radix and glabella a few months back, and I really liked the augmentation. Anyway, I’m intending to get a rhinoplasty to augment these areas permanently next year. As such, I was wondering if it were possible to do so and if so, what kind of material will be used? I understand that rib grafts are used for the bridge, but can it also be used for the radix/glabella? Secondly, I’m hoping to get a touch up with some fillers some time in December. Will it be fine for me to do so, or will repeated treatments of dermal fillers complicate the rhinoplasty?

A: A radix augmentation rhinoplasty can use either autogenous or synthetic materials. But, in my opinion, cartilage grafts are the best material to use for radix augmentation. They will hold up for the rest of your life without any risks of complications. The size of the radix defect and the volume needed will determine where the cartilage should come from. (i.e., donor site) While rib cartilage is always ideal in terms of unlimited volume, most radix augmentations can be done with septal or ear cartilage the vast majority of time. There is no problem with getting fillers again next month. It does not complicate placing a radix cartilage graft later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is in regards to the safety and security of chin implants. While I firmly believe such a procedure would improve my appearance my hesitation lies in the uncertainty of the implant being a permanent solution. To be specific my job is such that at times is of a physical nature and am worried that the implant could become dislodged. How is it kept in place? And are there certain implants designs that are better then others? Would hard impact to the chin or jaw cause it to become dislodged? Perhaps you know people in the Military who have had this done? My second line of questions are about the health risks of a foreign element placed in the body. Are there long term effects from having a implant inserted and is this something that once done should remain for life? Thanks for your time.

A: Chin implants, almost of any implant placed on the body, are the safest (less likely to have complications) in my long plastic surgery experience. There are a permanent chin augmentation solution as the material will never degrade. The implants are secured in place by small titanium screws so that they will never move or become dislodged. I have yet to have a case where a chin implant became dislodged or displaced because of trauma of any nature, including patients in the military. There are no health risks from performed silicone since it is a molecularly stable material that does not degrade or release any free silicone molecules.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want custom jawline implants placed.  I want to know how difficult the operation is to place custom Medpor jaw angle implants? I have had two surgeries, a bilateral sagittal split ramus osteotomy with genioplasty and an inverted ramus osteotomy to correct the sagittal split osteotomy. Even though I have custom Medpor jaw angle implants already fabricated, I am not comfortable with my current surgeon to place them…I want to know if you would be able to take over the case? What is the risk of infection? Thanks in advance.

A: Custom jawline implants have many advantages over standard shaped implants, particularly those made of Medpor material as they are more difficult to shape during surgery. Medpor jaw angle implants, and medpor implants in general, have a higher risk of infection because of their porous properties than that of smooth nonporous silicone. Thus these implants must be handled with great attention to detail. The implants must be impregnated with antibiotics, and that is important and easy to do, but the far more important issue is adequate soft tissue coverage over them. This requires careful dissection of the tissue flaps over the jaw angles and great attention to a water tight closure. Having had two prior procedures before, this makes this pocket development and closure more challenging due to scar but, in my experience, can still be done very successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom facial implants. I currently have a jaw/chin implant in place which I want removed and replaced with a wrap around, custom made jaw implant (and possibly a cheek implant replaced). Is this possible to do as one surgery, I was diagnosed with a mild case of hemifacial microsomia, so my cosmetic procedures were focused on only one side. I had a single jaw angle implant placed on the left side, and 1/2 of a chin implant with an extending wing place on the left side as well. I also has cheek implants placed on both sides, and one appears to be much more prominent than the other post-op. All of these implants were done during one surgery, and I believe they are all silicone implants. I would like to create more symmetry and balance in my entire lower face, and provide more jawline definition while maintaining a feminine look (no squareness in the jaw, as the left is now). 

A: With your history of congenital facial asymmetry and an attempt using standard stock implants, the only way to really make significant improvement is to have custom facial  implants made. With the computer, all bony asymmetries can be precisely corrected and precision fit of the implants can be obtained. You probably have a very good result from the prior surgery but it just shows the limitations of using standard-sized implants for a face that is not normally formed. (asymmetric)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-surgical rhinoplasty. I am a 32 year-old female who does not like her nose. My nose has a dent and a crack in it. It has always been there as long as I can remember but as I get older it seems to be getting worse. I am scared to get a surgical nose job because if I don’t like it I will be stuck with it. I know an injectable rhinoplasty is not permanent but it is less scary to me.

A: A non-surgical rhinoplasty, also called an injectable rhinoplasty, is a quick and fairly simple procedure that can be done in about 15 minutes. The only type of nose problem that is amenable to injection are those that can be ‘cured’ by the addition of volume. These include a deep radix, a nasal hump, indentations, depressions and some minor drooping tips. While almost any of the current injectable fillers can be used, it is safest to use a hyaluronic-based filler (e.g., Restylane, Juvederm) as it has good linear flow properties through a 30 gauge needle. There usually is little to no bruising and minimal swelling afterwards. The duration of the nasal correction will last as long as the type of injectable filler used, most commonly six to nine months.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have done a lot of research regarding chin implant revision and your name keeps popping up. I have a very weak jaw line/chin and I have a medium middleman chin implant placed with the wings cut off. The surgeon had to go back in three times intraorally to fix protruding wings and misplacement. The implant is still very high up and pushing my bottom lip up. I also have permanent muscle damage to my lip. I have denting and scarring in my chin. My last surgery was 6 months ago. I would like my neck to be tighter along with a new implant. I would also like to see if a revision rhinoplasty would fit in my budget. I had nose surgery about two years ago. The surgeon performed a pinch rhino when I’m more concerned about the bump in my nose. It still looks quite bulbous, I would like a small petite nose. I have attached several pictures and the web page called real self with other pics and doctor’s comments. Thank you for your time.

A: From a chin implant revision standpoint, intraoral placement if not placed in the proper position low on the chin bone and screwed in, has a high risk of riding up high in the chin. To properly revise this implant, the questions are whether to keep this existing implant and properly position it (ideally now from a submental approach) or to change the implant to a different style. Since you have never had a proper assessment of what this implant offers due to its many revisions and still high position, that may be a hard judgment for you to make. I would suggest a submental approach with a new implant altogether, removing the old one at the same time.

From a nose standpoint, there is certainly room for improvement from both a better hump reduction and a shorter, thinner and slightly more uplifted tip with a revisional rhinoplasty. I have attached some imaging to show what I think can be done from where you are now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fractional laser resurfacing. I had acne scars on my cheeks and decided to get revision surgery. A plastic surgeon suggested dermabrasion only on my cheeks. This left the area hypopigmented, uneven texture, and raised in the form of hypertrophic scars. I’m under the impression I can’t repigment the area. I’m using retinA to even out the texture and have received kenalog injections to reduce the hypertrophic scarring. However, since the injections are localized, and the scarring is over a broad area, I’m not getting the results I am seeking. I read a post by you where you suggested CO2 laser followed by topical corticosteroids which I believe could flatten the entire area. I’ve attached pictures for your review. I’m not sure if you can get an accurate understanding of my situation from the pictures. Note: the indented area on the left side of my cheek is due to a kenalog injection. I’m hoping this will fill in with time. 

A: Fractional laser resurfacing would be my treatment of choice for broad-based hypertrophic scarring from a prior dermabrasion. To prevent any recurrence, topical sterioids should be used as soon as the area is healed after about 5 to 7 days. Their penetration is aided by the channels cut into the skin by the fractional laser ttreatment. Whether the indented areas from the kenalog injection will fill in over time depends upon how long ago they were done and how many injections were done. If more than three months after the injections you should consider spot fat injections into the indented areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a jawline implant. I had a procedure to correct my jaw prognathism and teeth malocclusion. The surgery included sagittal split surgery of the mandible and LeFort osteotomy of the maxilla. While the LeFort osteotomy went well, unfortunately the sagittal split surgery which the surgeon had perform on my mandible were not very satisfactory. I’ve consulted with surgeon regarding the condition of my mandible and they all unanimously agree that my mandible were overly cut which resulted in an uneven contour of my lower jaw. The lining of my lower jaw project an unusual angle which stick out near the middle of my jaw. I had twice use fat graft to augment the area to recreate the mandible angle jaw line. While I am quite please with the result, unfortunately my body absorbs the fat rather quickly. I am looking into a more permanent solution, Such as silicone and synthetic bone. So here are my questions

1) Can silicone implant be used as an alternative to recreate my over dissected jaw line without adding width to my face?

2) I understand that synthetic bone can also be use to recreate my mandible jaw line. Assuming if silicone can also be used to recreate my mandible jaw line, which one would you suggest is a better option in term of result, Synthetic bone or silicone implant?

3) I am aware that both silicone implant and synthetic bone have its fair share of complication and risks.  I am aware that both synthetic bone and silicone could to some degree absorb one own bone resulting in asymmetry.  I am also aware that infection is also a likelihood. Beside the complication which I already mention, is there any other associated risk with either silicone implant or synthetic bone.

4) Unlike silicone, synthetic bone will create a permanent result. Assuming if I am unsatisfied with the result or infection occur, it there any alternative revision method?

5) What is the risk of nerve damages with this kind of procedure? 

6) And finally could you please provide a detail explanation of each method? For example how would you secure the silicone implant to the mandible? Where is the incision site? How long is the surgery? etc.

Thank you for your time and attention. I look forward to hearing from you very soon.

A: Thank you for telling your surgical history and describing your mandibular problem and need for a jawline implant. Your bony defect is really an absence of the jaw angle area. This is confirmed by the successful, albeit short-lived, fat injection augmentation results. In short, you appear to have an indentation probably at the location of the vertical bony cut of the sagittal split osteotomy. While there are multiple methods to treat this bony jawline/jaw angle defect, without question the best method is a synthetic implant. One can argue that it could be comprised of either silicone or Medpor material (I have used both very successfully) but the key is the implant design. Adding vertical length in an appropriate shape is far more important than the material used to create it. Either way the implant is placed from inside the mouth (like the sagittal split as done and secured to the bone by screw(s) Unlike your description, I have not seen the complications of implant migration, lack of permanency or a high rate of infections. There is no risk of nerve damage from this procedure. It is one I have done that is very similar to that of replacing cut off or amputated jaw angles. The key is designing the proper implant shape which can be made to add length but not width. Ideally, it should be made off of a 3D CT scan to exactly mimic that of a more normal shape. At the least it should be handmade off of a model made from a CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a necklift question. I want to know why you can’t just make an incision behind the ears and pull the skin up. When I pul the skin back along my jawline all my wrinkles disappear. This seems like such a simple thing to do so why is a necklift not done this way?

A: You are basically describing how a necklift (lower facelift) is done. There are variations of where the incisions are placed around the ears and whether the deeper tissues are manipulated and tightened . When you use your fingers to create a ‘facelifting’ effect, here is the trick to see where the incisions must be placed. First, the finger traction test must be done right next to the ear not more forward along the jawline as that creates a false result with too much of a change. The fingers must be placed from where the point of pull actually comes from by the ears. Secondly, put your fingers in front of the ear as well as behind the ear and do the lifting. You will see that a far more effective change occurs in both the jowls and neck when the pull is done from the earlobe and upward. This indicates that all effective lower facelifts must have an incision along the front of the ear to create an adequate skin movement. How far the incision goes on the back of the ear is determined by the severity of the neck sagging problem. In short, you can not have an effective lower facelift by an incision limited to just the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in your temporal reduction procedure. My head is an unusual shape and size and increases in size above the the ears quite dramatically. Please see the pictures attached. Is there anything you can do to reduce he bulge and make it look more normal?

A: Temporal reduction is one of many head reshaping procedures to change abnormal contours. I can see from the pictures you sent that you have a very prominent bulge above your ears. This is caused mainly by the size and shape of the temporalis muscle. While many people think this is due to the shape of the bone, it is really mainly a muscle thickness shape issue. This can be dramatically changed and a near flat temporal profile above the ear achieved by temporalis muscle reduction. This is done through a small vertical incision above the ear. The prominent part of the muscle is released and removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in body contouring after weight loss. I have 2 very large, deep atrophy dents, one on each hip from kenalog injections. I have arthritis and fibromyalgia in my hips. The pain is unbearable, and has left me disfigured. I also have lost 100 pounds over the past 3 years and have bags of fat instead of breasts. And I have a giant stomach that is all skin and fat that hangs dramatically.

A: Body contouring after weight loss, also known as bariatric plastic surgery, is commonly done today. When one loses 100lbs or more, as often happens with successful bariatric surgery or great personal diet and exercise efforts, many expected body changes occur. The large stomach deflates and become an apron that hangs over the waist line, the breasts lose their volume and hand down onto the stomach like two empty bags of skin, and the once larger arms and thighs sag. These common extreme weight loss concerns are treated with extended tummy tucks or abdominal panniculectomies and sagging breasts are changed with full anchor scar pattern breast lifts with implants in most cases. By getting rid of these tissue overhangs, combined with the weight loss, back and hip pain is often lessened. At the same time the large hip dents, which have occurred as a result of subcutaneous tissue atrophy from the steroid injections, can be treated by fat injections or even dermal-fat grafts depending on its depth and degree of skin tethering.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m an Asian American and I’ve been thinking of a few cosmetic procedures to enhance my flat face and that is rhinoplasty and midface augmentation.I’ve decided to go with the midface first. Being that, I’d like to know your inputs on the area of my midface that needs to be augmented for a more chiselled, three-dimensional look. I know that there a few parts to the midface – premaxillary and maxillary area for the anterior cheek ( I may be wrong on that ). So with that being said, what would you say about having both paranasal and malar implants done together? (for the case that I may need both) Would that cause a great incremental change in my facial projection compared to just one procedure done?

A: In looking at your face, which is not atypical for many Asian males, you might consider a somewhat different approach. The best procedures for ‘pulling your face out’ (increasing midfacial projection is a rhinoplasty combinjed with paranasal implants. It is very difficult to give much definition to broad wide cheeks without burying the rest of the midface behind them. (making the nose look even smaller) Look at the imaging I have attached to see what effect is created by initially pulling the nose and its base out. With your specific facial shape, this is where the real value is in any plastic surgery for you. The cheeks can be enhanced by probably not in the ideal chiselled fashion that you seek, I don’t think that is realistic for your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to decide between a lip lift and a lip advancement. I am aware of some of the differences between the subnasal lip lift and the vermilion  lip advancement. I have read through the information concerning these two procedures on your website. As I understand it, both procedures will reduce the distance between the lower portion of the nose and the upper lip. However,  the vermilion lip advancement will result in an increase in vermilion show throughout the entire upper lip, while the subnasal will only lift the central portion of the lip. In addition, the lip advancement  requires an incision along the entire upper lip which will result in a scar that will most likely be longer and more noticeable than the scar underneath the nose from a bullhorn lift. I would like to know any other advantages/disadvantages concerning both procedures that I may not be aware of. Based on the photos that you have before you, I would like to know what your recommendation would be in my particular case.

A: You seem to have a good grasp on the differences between a lip lift and a lip advancement. The decision then for any patient is balancing the concern about the scar vs. the degree of improvement they desire. Unless one has an absolute pencil thin lip (in which only the vermilion advancement will be effective), many patients opt for the subnasal lip lift due to less scar concerns even though only the central part of the upper lip is affected. Doing a subnasal lip lift first does not exclude the option of proceeding later to a vermilion advancement if one finds they want a more significant result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some facial reshaping procedures. I am 54 and desire more of a heart shape to my face. It is long and not as feminine as I would like. My nose is a bit long and wide on the bridge (from the front esp.) Looking younger would be great, but looking more feminine and therefore prettier is my main goal. Wider temple area/distinct cheekbones, tighter jaw to neck angle, more of a right angle beneath chin-to-neck, and a feminine nose are some ideas I have. My jawbone has reabsorbed somewhat, according to my dentist. But I need YOUR trained eye to tell me how to accomplish my goal of looking more feminine, losing the chub underneath my chin, creating a prettier facial shape in general. Thanks so much for giving me the straight scoop.

A: In looking at your pictures and understanding your facial reshaping goals, I would recommend the following changes.

CHIN A V or triangular shaped chin implant augmentation with the objective or bringing your chin forward, which is short, but making it narrower at the same time.

NOSE An open rhinoplasty to narrow the nose from the bridge to the tip with some slight shortening and elevation of the tip with nostril narrowing.

CHEEKS Cheek implants that produce some a combined malar/submalar (shell) effect. This with the chin helps create more of a heart-shaped face.

TEMPLES Subfascial temporal implant to correct the hollowing and increase the bitemporal width.

EARLOBES I know you did not mention these but these seem a little bit and stick out and reducing them adds a touch of femininity to the sides of the face.

I have attached some computer imaging predictions of how I see these changes affecting your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a back of the head skull reshaping procedure for the back of my head. When I cut my hair everybody can see the lump so I’m very frustrated about that and I like to know about this procedure to see what can be done to make that bone reduced in size by in filling around it. I was born like this and it has been there as long as I can remember. What can you do to fill around that bone is sticking out to reduce that size so make it look better? Thank you!

A: Skull reshaping of the back of the head is common for many types of contour issues.  I believe the lump on the back of your head to which you refer is a variant of what I call the occipital knob deformity. This lump of thickened bone occurs at the confluence of the nuchal ridge line of the occipital skull in the midline. One could argue whether this bone is too thick or whether the bone that is around it is deficient, either problem of which makes it stick out. From reading your description, it sounds like your concept of contour improvement would come from building up the bone around it using a bone cement material. That is probably the most effective contour approach and would completely eliminate that appearance. That is a very straightforward procedure to do using about 30 grams of material through a small (8 to 9 cm) horizontal incision in the occipital area above the lump and could be done as a 90 minute procedure under anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision. I am a black 26 year old female. I got to know about your practice online. I had a vertical scar on my face as a result of a bottle injury from three years ago. The scar is on the right side of my face just below my right eye on the cheek. So last year I had a scar revision where the Doctor surgically cut out the scar and stitched it up linearly. it looked good after that but some months later it started widening with some areas being indented and other side raised. I want to visit your practice for a scar revision. My mother also has keloids on her body, about two on her stomach, one on her breast, another at the pubic area. It itches her a lot and she wants to have them removed. She has had it removed it before but it grew back so it is a keloid. I have attached a picture of my facial scar and pictures of my mother’s keloid.

A: Your previous failed scar revision by a simple linear technique indicates that an exact repeat of that type of scar revision will result in the same outcome. Your next scar revision should be more of a geometric broken line closure pattern so that it is less likely to widen again. With your mother’s obvious keloids and their history or recurrence, their excision should be accompanied by either steroid of 5FU injections to try and lessen their likelihood of recurrence.

Dr. Barry Eppley

Indianapolis, Indiana