Your Questions

Q: Dr. Eppley, I am considering having Lasik eye surgery. If I did get it, how long after Lasik should I wait until being able to safely have a rhinoplasty. Would it be safer to wait to do Lasik until after having the nose surgery?

A: Rhinoplasty does not affect Lasik (corneal) eye surgery in any direct way. So, in theory, it should not matter whether rhinoplasty is done before or after corneal modifications. However, rhinoplasty does involve working around the eyes and often the eyes are either protected by corneal shields or the lids are closed over the cornea by tape. Such protective manuevers always run the risk of causing a corneal abrasion even though their intent is to prevent that exact problem. Therefore, if I was a patient I would prefer to have my rhinoplasty done first and then have the Lasik surgery done afterwards so the rare risk of that problem which could be occur during a rhinoplasty is eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 63 year-old female who just recently had a facelift. Because I am thin, I really had no fat just loose kin in the neck and jowls. Now that I have gotten the skin tightened up, how can I keep the facelift in place? I have read about a lot of things such as Thermage, Ultherapy, Exilis and others and, while they sound good in theory, I have read and been told that they don’t work for a lot of people. Some have said that the only really effective method of skin tightening is through collagen regeneration using a fully ablative CO2 laser. But laser resurfacing of the face can be associated with long-term pinkness of the skin. What do you recommend?

A: The reality is that nothing can keep a facelift ‘in place’ forever as surgery does not stop the effects of time and gravity. But there are certainly things to do to help slow down the process. Skin tightening and collagen rebuilding would be the correct approach after a facelift and, for many, should be considered maintenance therapies. There are numerous enery-based devices for skin tightening and you have named a few of the most well known. I do think they do have some benefit even if it is not the same for every patient as each person’s skin is different. In my practice, I currently offer Exilis and BBL (Skin Tyte) as methods of skin tightening maintenance after a facelift in which a series of treatments (usually 4) could be once a year. If appropriate based on how many skin wrinkles one has, light laser resurfacing is also a good choice and can be done with the other skin tightening treatments. Just don’t have any deep laser treatments but more regular lighter ones. That will avoid the prolonged redness and recovery. These treatments will not stop the aging process completely and more tissue sag is to be eventually expected but it will slow down the process and maintain the facelift result much longer. Also don’t forget basic preventative measures for skin aging which includes avoidance of excessive sun exposure, no smoking, a stable weight and a good daily skin treatment regimen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, This may be a very very unrealistic but part of my head is flat and I am 21 years. I was wondering whether there was literally anything you could do to improve it at all. I am willing to pay anything for it. Maybe even a material to fill some of it in. Any ideas would be great.

A: Skull augmentation/modification is a very common surgery in my practice. One of the most common reasons that it is done is for flat areas of the skull, usually on the back part. The realistic part of this surgery is not whether it can be done but whether enough change can be done to make the procedure worthwhile. The limiting factor in all skull augmentations is how much the scalp can stretch to accomodate the expanded skull contour. I will need to see some picture of your head and the area of concern to determine if this may be a procedure for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about you on Real Self and would like to have surgery under you. I have an short face (abnormally short lower third of face) but, oddly, also mandibular prognathism. Could you push my jaw back and at the same time lengthen my face?  I have attached my original front and side photos, and also some virtual post-surgery photos to aid in your diagnosis. The lower third of my face is already equal to 1/3 of the length of the midface. After bimaxillary orthognathic surgery (see the post surgery photos), notice how my lower third becomes extremely short. Although the post surgery side profile is good, the post surgery front profile is horrendous! I am also concerned about the unaesthethic effects on the nose of lefort 1 as well as the risk of bimaxillary protrusion. I was wondering whether you could beautify my side profile without making the lower third shorter, perhaps with orthognathic surgery alone, vertical distraction + orthognathic surgery or lefort 2 alone. Please let me know of any other options. Thanks!

A: The virtual after surgery photos that you have shown are not realistic nor would they look that way. You undoubtably need a LeFort 1 advancement osteotomy but whether you need or can have any change to your lower jaw is unknown based on the information you have presented. What will happen or be needed to the lower jaw completely depends on your occlusion (bite) and how it fits when the maxilla comes forward. You can not just move your lower jaw any way you want, it does not work that way in orthognathic surgery. You may need the lower jaw set back somewhat with the maxilla coming forward but that will not change the vertical height of the lower 1/3 of your face in any significant way. You do not need anything more complex than a Lefort 1 advancement with or without a mandibular setback.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had liposuction on my stomach in 2009. I work out 3 to 4 times a week with a trainer. I actually look bigger than I did before the liposuction. I have gained fat in my back and my breasts went from 34B to a 36C. I look like an ogre. My question is would SmartLipo be an option for this excess fat on my back? Or will I face the same results (fat returning on another area of my body)? I am completely miserable. Thanks.

A: Based on your description of your liposuction experience, I am assuming that you had improvement from the procedure in 2009 and have gained weight subsequently in other areas of your body. When considering liposuction now, your concern would be that fat would just accumulate somewhere else again. Your concern is based on the fat redistribution theory that states removal of fat from one body area will merely cause other areas to get bigger. (fat homeostasis) While commonly believed, this theory has never been proven to exist on a wide scale basis although perhaps it may be true for a small number of people. Whether it exists in you or not I do not know, but let us assume for the sake of this conversation that it is true. Then fat removal from the back will cause it to accumulate elsewhere although there are not many other places that it can practically go.

That discussion aside, fat removal from the back is difficult with liposuction because it is a different kind of fat which is more fibrofatty and harder to to remove. (unlike the stomach area) Smartlipo, a fiberoptic laser method of fat emulsification prior to suction extraction, is a good technique for this fibrous back fat.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in a more structured feminized face. I am 40 years old and have wanted to balance my face my entire life. The fat never dissipated with age so I now find it agonizing. I also think chin augmentation would help but I am not sure about that.

A: In looking at your face, I believe your fat concerns go beyond the buccal fat pad area. Most people have a misconception about where the buccal fat pad lies. Even though it is a fairly large fat collection, it only occupies a small area immediately below the cheek bone. It does not extend down near the mouth area which is a different area of fat in the subcutaneous layer know as the perioral mounds. When looking for facial thinning in the cheek area, it is usually necessary to combine partial buccal fat pad reduction with perioral mound liposuction.

I can not tell about the potential benefits of chin augmentation based on just a frontal picture only. I would need to see a side picture. Chin augmentation is usually only beneficial to facial thinning if it helps elongate the face and helps makes the chin more narrow in the frontal view.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I suffer from sever temporal wasting. It’s rather noticeable. I’ve heard fillers are recommended but are they for minor filling and not severe cases of hollowing of the temples? Can they really fill my temples?

A: While injectable fillers or fat can be very good for more minor or moderate cases of temporal wasting, they have limitations in deeper temporal depressions. When it comes to more severe wasting of the temporal regions, fillers do not do a good job of augmentation as they take a  fair amount of volume (high cost) and are temporary anyway. Fat injections are often a problem in severe temporal wasting as the patients may have little fat to harvest on the rest of their body. There is also the issue of what caused the fat wasting in the first place which can work against any transplanted fat survival.

Synthetic mplants as part of a more complete treatment strategy for temporal wasting can be more effective and also are permanent. Different-sized temporal implants are available to fulfill various volumetric needs.

Q: Dr. Eppley, I lost a chunk of my nose — right on the bridge. It was not a cut — a chunk of skin is missing – down past epidermis and dermis into subQ.  It has a nice granular base. I know it will have to scar — is there any way to help it heal while keeping scarring minimal?A certain wound gel or something?  I usually fill in missing skin with redder tissue that is hyperpigmented. Thanks for any advice. 

A: As to your nose, I don;t think there is really any magic about what makes skin heal. Given that you have a full-thickness skin loss that is now granulated, what you need is something that will help in re-epithelize faster. The topical agent that i recommend to my patients in this situation, believe it or not, is A & D ointment. (as in Vitamin A and D) While it is most commonly know for use in diaper rash ( a very superficial de-epithelization problem), vitamins A and D are well known agents that skin cells need to grow. I have found this very simple and inexpensive topical cream very helpful in such cases. It has a bit of an unusual odor because the vitamins are derived from cod liver oil which is also why the cream is a little dark or brown-colored. Just keeping the area a little moist with it should help it heal quickly over the next 7 to 10 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting forehead augmentation and I have some questions. How much can the forehead be built out? I am thinking 10mms is the perfect amount. Is that too much? As a female I want to make sure I get a good convex shape with a largely vertical inclination to my new forehead shape.

A: With 10mms of increased horizontal projection,  you might find it to be too big particularly for a female. (it can be amazing the difference a few millimeters makes, so 7mm is probably more appropriate) Achieving the desired female forehead shape is usually achieved as with most forehead augmentations what I see on the operating table during surgery is what is achieved. This is because there are fewer soft tissue variables involved in contrast, for example, a rhinoplasty. As long as one gets the desired underlying shape and volume, the external result will look exactly like it. In other words, in forehead augmentation it is pretty much a 1:1 ratio of internal to external change. Good attention must be paid to the brow area, however, because it is the lowest part in the forehead flap dissection can be difficult to get the cranioplasty material low enough. Good dissection and release of the brow tissue is necessary.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I lost 90 lbs over the last 2 years. I have been body building during that time and cannot seem to get rid of my stubborn belly skin/fat. I have some abdominal definition but too much skin underneath my navel. Of course, I am very concerned about cost and surprised at myself for even inquiring about the procedure, but I am almost to the conclusion that a mini TT is the only way I can get rid of the extra skin. I would love your expert opinion and recommendations! Thanks for taking a look at my pictures for me.

A: You are to be congratulated on making such a body change. Not many people can lose nearly 100 lbs and end up with a fairly well sculpted body. But you are correct in that you have done all you can do and the lower abdominal skin will only respond to surgical removal. The good news is that it is tremendously successful and will put the final touches to your body transformation. This mini-tummy tuck is what most men actually need as their abdominal skin shrinks much better than women because of retained skin elasticity. (never having gotten pregnant) Also male tummy tucks do not require manipulation of the rectus muscles (muscle sewing) for the same reason. This makes everything about the male tummy tuck a little easier than that of many women. The biggest problem in men is to control their activity level afterwards for three weeks to avoid a postoperative fluid collection. (seroma)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was considering a lip lift.  If I send you my photo would you be able to advice me if the lip lift would be a good solution. I had open bite and orthodontic treatment and so my upper teeth moved back a bit and the top of my lip is not as full or not lifted up as it was before resting on my teeth which were slightly protruding. I was considering either fat injections or lip lift. I don’t know if fat injections applied skillfully can also reshape the lips adding volume in the centre part, making cupid arch more prominent. The teeth on my side tend to show more when i smile only slightly, the upper lip has a shape which is rising where my third tooth is and going slightly down where the very front tooth is. I do not seem to have very long upper lip, it’s just rising up in the wrong place. I think an upper lip lift may correct it since the corners go down a bit it may look slightly surprised unhappy look and if I shorten the lip too much the lips will not close completely. Could i reshape my upper lift with fat injection so they turn up more in the centre or would the lip lift be more advisable? I greatly appreciate your advice. Also,  how long do the results of lip lift and lipofilling last?

A: I am afraid that you find yourself in the midst of a quandry, which is not that uncommon with lip enhancement procedures. While a lip lift will create the greatest amount of central lip pout that will be maintained, it is not really an appropriate procedure in someone who does not have a long upper lip. Conversely, fat injections will not really reshape the cupid’s bow and their take is always suspect. When one finds themselves in such a quandry, it is always best to do the one with least risks first (fat injections) and let those results prove that a lip lift would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to make my butt bigger by using fat injections instead of synthetic implants. But I don’t think I have have enough fat of my own to do ti as I am too thin. Is it possible to get body fat from my boyfriend to inject in my butt instead? He has plenty to give.

A: Buttock augmentation by fat is known as an autologous procedure, meaning fat is transferred from one part of the body to another. You must use your own fat otherwise it will be rejected and/or get infected. Fat grafts are just like any other organ or tissue transfer, your body’s immune system will only recognize itself. Anyone else’s fat will be seen as foreign and be attacked. If you don’t have enough fat on your own, you would then need to consider getting implants for buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two different sized ears, my right ear is undesirably larger and protruded and my left ear is smaller and oddly pointed at the top. I would like to have the right ear’s shape corrected as well as brought inwards and the left ear reshaped. Basically both ears to look the same and not protrude, thanks. I have attached picture of my ears so you can see what I mean.

A: In looking at your ears and taking measurements, the vertical height of both ears is identical. So neither ear is actually larger than the other. The only issue that I see with the right ear is that it protrudes a bit. The left ear has a deformity known as a Stahl’s ear (Spock ear) where it is pointy due to an abnormal cartilage fold on the back of the ear. This gives the ear a point at the top portion of the helix. Your ears can be made more symmetric by a setback otoplasty on the right ear, bringing it closer to the side of the head, and a cartilage reshaping procedure on the left ear. I suspect the left ear needs to be brought in somewhat as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 37 year-old man who had a chin implant done put five months ago using biocoral in a subperiosteal position placed through the mouth. This was not my first intent to correct my chin. Afew years ago a sliding genioplasty was done which failed (muscles put the fragment back in position) This time it went bad again, implant and bad postop tension made the muscle attachment drop and intraoral incision is not healing properly. (granulation tissue is going out of stitch defects) I really need a surgeon confident in re-anchoring mentalis muscle. I also need correction of my implant to check if it’s transforming into bone properly, there is some imbalance to correct and a prominent screw to remove.

A: Let me first make some general comments about genioplasty just based on what you have described. First, Sliding gebnioplasties should not fail to hold their position in today’s world no matter how strong the mentalis muscles are. Contemporary plate and screw fixation holds any genioplasty in place. Either the fixation was not done properly or wire fixation was used, an historic method of fixation last used in the 1980s. Secondly, an hydroxyapatite block implant (biocoral) will never transform into bone. Bone may grow up against it but it will always be like a synthetic implant. Third, it is now apparent that you have a non-healing wound likely caused by chronic implant exposure and low-grade infection. This is confirmed by the granulation tissue present and the exposed screw. It is now apparent that this implant is doomed and there is no way muscle is going to be pulled up over it and heal. Either it is too big or chronically infected, but either way keeping the indwelling implant is doubtful. I suspect you are going to have to look at implant removal, a new sliding genioplasty done and mentalis muscle resuspenion to end up with a healed and an improved aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a nephew with occipital plagiocephalhy. He’s 2 years old and we’ve been told there’s nothing else to do from a medical point of view. I’d like to know if there’s anything else that can be done, and when will it be a good time for him to go through any procedure if there’s still an option. We’d also like to know if it would better to wait, or to act now if there was something that could be done. Thanks.

A: At two years of age, a flat spot on the back of the head (occipital plagiocephaly) is not worthy of major skull surgery. (taking the bone off and reshaping it) This is what is meant by ‘nothing to do’. This does not mean there is actually nothing to do because there is, just not that particular surgery. Building up the flat area on the back of the head (skull augmentation) would be the appropriate surgery. This can even be done through a very small incision using an injectable bone cement technique. (injectable cranioplasty)

The question is not whether it can be done but when it should be done, if at all. There are no concrete answers to these questions. Such surgery is simple and takes less than an hour to do. Whether the size of the flatness justifies surgical improvement is a personal question as well as the timing of it. It can be done at two years of age or age 60. Correcting the flatness of the back of the head is a cosmetic issue. Thus the procedure and its timing are an individual decision.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been getting a variety of injectable fillers for chin and cheek augmentation over the past few years as I don’t have the time for surgery to get real implants. And I am not sure I want synthetic implants anyway. Is there something else that can be injected that would be permanent but would create the same volumizing effects. If there was that would great.

A: There is a real need that has developed in aesthetic facial enhancement for an intermediary procedure between temporary injectable fillers and permanent facial implants for augmentation of the three classic highlights of the face, chin, cheeks and jaw angles. The emergence and phenomenal spread of injectable filler use has created the need for this ‘in-between’ step as more and more doctors are pushing the envelope using temporary fillers as a means of facial skeletal augmentation. (even if they are not putting them all the way down to the bone) As a result, patients now seek injectable therapy for what was once exclusively a surgical solution.

The one material that shows the greatest promise as an injectable facial enhancement method are the so-called bone cements. All  bone cements are liquid and powders that go through a putty phase and then set into a hard bone-like implant. They are composed of differing forms of hydroxyapatite and calcium preparations so they are perfectly natural and 100% biocompatible. Some are now available that can be injected down to the bone level after they are mixed and then set up in just a few minutes. They can be molded while they are setting to get the desired shape, albeit blindly. So an injectable cement combines the benefits of permanency with the avoidance of a surgical incision, bigger operation and recovery and a mass of implanted synthetic material. One of these very promising bone cements is OsteoVation. A tricalcium phosphate mixture, it fulfills all of the requisite handling and insertion properties to be an injectable permanent facial implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a significant augmentation rhinoplsty done using rib cartilage. I have a very specific goal and look that I am after and I have attached a powerpoint presentation to show what I want to achieve. I have chosen many noses that I look and don’t like. I want to be as specific as possible as I want to avoid a revisional surgery at all costs and don’t want to be disappointed in the result. Please review these presentation and tell me what you think.

A: Thank you for sharing the powerpoint presentation. I don’t think anything you could say says it better than these pictures. My general comments about achieving these aesthetic goals are important for you to understand.

Rhinoplasty surgery is nor like Photoshop and there are a lot of other variables, other than how much cartilage graft you insert, that influences how the result will look. There is the thickness of the nasal skin, how well it reacts to injury and shrinkage, the fact that there is an internal cavity with two skin-lining openings, how well any grafting shapes and takes etc. Nasal goals are much more difficult to achieve particularly when the goal is model pictures that have been photoshopped. (most plastic surgeons cringe when they see a photo album of model pictures) While it is important to have ideal goals, the variables of the nose make that a difficult challenge particularly when the changes are going to be dramatic. I think it is important to realize one of the realities of rhinoplasty surgery…the need for revisional surgery is not rare. No one wants to have it…the patient doesn’t, the plastic surgeon doesn’t…it is disappointing for all involved. But the simple reality is that no matter how well planned and executed any rhinoplasty surgery is done…it does not always turn out perfect. The more lofty the goal, the harder it is to achieve. Rhinoplasty surgery is simply not a 1:1 ratio of change to result in every case. I emphasize this point to you, not exclusively because of your attention to detail, but because the tip area of the nose can be very unpredictable as to how refined it can become…and that is a very important aesthetic goal of yours.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know the cost for under eye surgery to remove bags. I don’t believe I need lid surgery.

A: Thank you for your inquiry. Your question as posed is contradictory. The removal of eyelid bags is a form of eyelid surgery that, if done in isolation, is accomplished through an incision inside the eyelid without outward skin removal or an imperceptible scar along the lashline. This is known as a transconjunctival lower blepharoplasty. While this type of lower eyelid procedure does not remove skin it is often combined with adjunctive lower eyelid skin tightening techniques such as chemical or laser peels. When excess skin as well as herniated fat exists, the removal of skin and fat is done through an external incision. This is known as a transcutaneous lower blepharoplasty.

I believe you were likely referring to the desire for transconjunctival lower blepharoplasty when you made the statement that ‘I don’t believe I need lid surgery’. That cost is usually in the range of $ 3,500 to $4,000 for both lower bags. If skin removal is needed this wil, raise the cost to about $ 4,000 to $ 4,500.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My brows and eyes give me a cold look and I’d like to have a softer image. I am consider getting brow reshaping, but what else can be done to improve my appearance. I have attached a front and profile picture to see what you think can be done.

A: Thank you for sending your photos. I would not disagree that your brow bone shape and promience do give your eyes a bit of a harder look. While the brow bones can be surgically reduced, there is always the tradeoff of a scalp scar to do it. That can be a precarious trade-off in men based on their hair pattern, density and potential hairline instability. I am niot ruling it out for you but I think there are other facial issues that I think would be equally, if not more effective, that can be done with no such trade-off. Your prominent nose and short chin create a significant amount of facial imbalance. Their alteration by reduction rhinoplasty and chin augmentation puts your face in better balance and would help to give your face less of a cold look. I have attached some imaging to see what you think of the nose and chin changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about mentalis resuspension. Can you explain what is the procedure you perform and what is the percentage rate of success. I have heard that this procedure will never restore the lip position back to normal (prior to when the injury occurred). I also heard that most of the time the lower lip descends back to its malposition (as though the mentalis resuspension never occurred) within the first couple of months after the mentalis resuspension procedure.

A: I am not sure where you have been getting your information about mentalis resuspension and under what circumstances or techniques that it is performed. There is a difference between uplifting the chin tissues from an injury vs attempting to alter a naturally low/genetic chin ptosis. Soft tissue sag of the chin has a higher success rate when its origin is that of an injury. The best mentalis resuspension technique uses suture anchors that can adequately lift and maintain the position of the muscle until they heal to the bone. The success of mentalis suspension is also enhanced by a concomitant V-Y mucosal lengthening procedure done at the same time which is helpful for improving the horizontal position of the lower lip. These are some general concepts and I would have know more about your particular chin problem to know how they may apply.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m unhappy with my face. I think the horizontal projection is very poor and the jawline is weak. Just starting to look into options and I would be happy to hear any ideas you have. My first thought was that chin implants might be helpful. I’m hoping to create a face that Asian and white women will find very attractive and projects warmth while also commanding respect in a business setting. I have attached a profile picture for your thoughts.

A: I am not sure what Asian or Caucasian women would necessarily find attractive or what facial appearance projects warmth while commanding respect in a business setting. But in looking at your side view pictures, I would agree that your chin is weak and out of proportion to the rest of your face. Having a more proportionate chin would give your face better balance and is what I think you would give you an improved facial appearance that may be considered more attractive as well as casting an image of greater masculinity. I have done some imaging on your side picture to see if you agree. The chin augmentation, which could be done by either implant or a sliding genioplasty, would benefit by concomitant neck liposuction as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about 3D-generated chin implants. I have read that a perfect implant can be created without the trial and error process through the Implantech company. When reading further I don’t know if it means it reproduces exactly what you have crafted or it reproduces a perfect chin implant based on the dimensions of the face. Could you please clarify?

A: a 3D or custom facial implant must be made off of a skeletal model, whether that is off of a 3D CT scan or an actual hand-held model that is made from a CT scan. Either way, the implant is made based on the surgeon’s specifications/dimensions and it is ‘perfect’ because it matches exactly what the surgeon envisions. It is not perfect because the computer or its software have some method of knowing how to make an implant that would look the best based on how the patient’s face looks or its dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going through a divorce due to domestic violence. I have lost a little over 100 pounds since I left my abusive marriage with our son. I for so many years buried my head into food. Even though I have lost all of this weight I often look in the mirror and cry due to the way I look. I feel empty inside, I want to feel beautiful and content with myself. I want back all of that confidence that he took from me. I have a lot of extra skin from all of the weight I lost. I am only 30 years old but I dress like a 40 or 50 year-old due to my body’s look. I don’t want to feel like I am dying inside anymore, I want to feel alive again, confident, young, and beautiful. These are the goals I want to achieve. Most of all I want to be able to bring my son to a beach in a bikini he is so young I do not want him to miss out on things due to my insecurities, He has suffered so much due to this divorce and domestic Violence. I try to keep a positive outlook on everything. I have attached some pictures so you can see what you have to work with.

A: Thank you for sharing your very personal story and in losing in the weight. This is obviously a transitional period in your life and changing how your body looks would be a complementary component to it. The excess skin and fat represent both physical and emotional baggage. In looking at your pictures, I can see that you would get some good benefit out of the following procedures… a full tummy tuck, liposuction of the lower abdomen (prior to its removal) and flanks with transfer to the buttocks, and a breast lift. Together these would all make a significant improvement in the shape of your body and reverse some of the effects of your prior weight gain.. All those procedures could be done together with the tummy tuck as the foundation procedure which is the one that really involves any significant recovery. Breast lifts are relatively painless and fat injections to the buttocks only as minimal discomfort.

While all four procedures would provide the most benefit in terms of body changes, the most important one is the tummy tuck with flank liposuction. That is the foundational procedure that produces the best benefit out of all the potential body procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw surgery over 20 years ago and am experiencing headaches and upper jaw movement. I saw a surgeon who took a c-scan and said there is no bone holding jaw in place just scar tissue. I am looking for consultation. I would like to find some one who has experience in this procedure.

A: Based on your description of upper jaw surgery, I am going to assume that this means you originally had a LeFort 1 osteotomy. This would be a standard horizontal maxillary osteotomy done right above the tooth roots. If done over two decades ago, it may likely have been secured at the time of surgery with stainless steel wires rather than the more common plates and screws used from about 1990 on.

To have upper jaw movement at this point, you would have to have a partial or complete non-union of the osteotomy site which is hard to imagine at this point in time after your surgery. But a CT scan would show the bony anatomy across the osteotomy site and should have been completely healed in with bone even at 6 to 12 months after surgery. So if the surgeon sees that now, I would conclude that it is a real phenomenon as unusual as it is. This should be evident clinically by seeing if the maxilla (upper jaw) has much movement in it.

The question now is what to do about it, particularly given your symptoms. If your occlusion (bite) is good, I would recommend a debridement of the osteotomy line, placements of plates and screws and bone grafting to provide stability and get at elast a partial union across the osteotomy site.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my face is very unbalanced as my chin is very short. This also makes my neck look fat even though I am at a good body weight. I have attached some pictures for you to tell me what you can do for my really short chin. It looks like the lower part of my face is just missing.

A: Here is a side view prediction based on the combination of a chin bony advancement (sliding genioplasty) combined with an implant. Your horizontal chin deficiency exceeds 15mms which puts you well beyond what any conventional chin implant can do. A chin osteotomy will advance you up to 12mms, which is better, but also not ideal. Therefore, in cases like yours I will put an implant in front of the advanced chin bone as well that will add another 5mms to the projection. The addition of the implant also has the advantage of its extended lateral wings which will fill out the sides, making the chin a little more square. That is an advantage for a male who benefits by a more square chin anyway. In addition, your thicker neck tissues would simultaneously benefit by liposuction under the advanced chin area to try and thin that out a little but.

The combination of a chin osteotomy and implant combined with neck liposuction can make some significant changes as the imaging suggests. This type of ‘extreme chin augmentation’ is necessary to get the best result in larger male chin deficiences like yours.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to get a forehead burr hole filled from a previous craniotomy that I had done. If you used hydroxyapatite (HA) material, would the HA be applied directly on the burr hole coming to direct contact with the dura? Would a mesh and screws be also used?

In addition, I want to get my brow ridges built up as they are a little flat for a guy. Do you favor having the the eyebrow implants custom-made or would you make them during the surgery? Can’t HA cause a necrosis of the surrounding tissue during curing? What would be the advantage of using HA for the eyebrow ridge implant over medpor, PEET, or any other existing material?

A: In answer to your questions:

1) When reconstructing/filling in burr holes, it is first necessary to dissect the soft tissue/scar from both around the hole and the bone edges to identify clearly the bony margins. This scar tissue directly lies over the dura so the material does not lie in direct contact to the dura. Even if it did, however, this would be of no consequence or concern. Because they can be some ballooning of the scar/dura into the burrhole, it can occasionally be necessary to push this tissue down so the bone edges of the hole are exposed. This is done with a small piece of titanium mesh (no screws) whose edges grip the bone to keep it in place.

2) I am not sure where you get the impression that any cranioplasty material, HA or even PMMA, can cause any tissue necrosis during curing. HA is a completely cold curing material that has no exothermic reaction during setting. Even PMMA, which does have an exothermic reaction during curing, is very mild and never exceeds 110 degrees F. The actual temperature at which tissue damage could occur is at 142 degrees F and above. Decades ago the original PMMAs had high cure temperatures but those versions no longer exist. This has never been an issues with HAs and, when they were introduced in the mid 1990s, that was one of their big advantages over PMMA, a neutral set temperature.

Brow ride augmentation can be done nearly 10 different ways, largely depending on what material is being used. In the right hands, they all can be effectively done from an aesthetic standpoint. What one has to look at then is the material’s biology, what is the process to place them and the cost to do it. The most biologically compatible material is HA because it is composed of the inorganic content of bone, calcium phosphate. This bone will bond directly to it and may even get a small amount of bone ingrowth. It is also the easiest to place and mold into a desired shape. All other typical synthetic facial implant materials, such as silicone, Medpor and Gore-tex, must be hand carved at the time of surgery from a block of material. While this is very doable, it adds to surgical time and the they must be screwed into place for stability. Materials such as HTR and PEET must be made beforehand off of a 3-D skeletal model. Between the costs of the model and the fabrication of the implants, this could easily add up to $10,000 in cost to the surgery. That would be acceptable if there was some overwhelming biologic advantage to the these materials, but there is not.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had orthognathic surgery of my upper jaw 2 years ago. My upper maxilla was impacted (5mm), advanced (5mm) and moved to the right (2mm) with a Lefort and lateral segmentation of my upper jaw. I got cheek implants, a mentoplasty without implants and jaw angle implants (porex) in standard size. I want my jaw angle implants removed and replaced as I am not happy with the results. My surgeon did a second surgery to try to file the existing implants and create more symmetry (one side is longer than the other with the implants) but even then the result is not good and the only thing to do is to remove the porex implants and replace with custom made. In addition to asymmetry I find that there is not a nice jaw line between the implant and my chin (not continuous line) which create a strange visual effect (it feels that the jaw implant should have continue to meet with my chin). To me is very important that the surgeon that is going to perform the surgery is both knowledgble and has a ‘cosmetic’ eye. I wish to have advice of how difficult this type of corrective procedures are.

A: I am not surprised that revision of porex jaw angle implants did not improve the problem. They are virtually impossible to merely ‘file’ in place due to their harder plastic structure. In addition, it is very common to have some disruption of the jawline between the chin implant and the jaw angle implants, particularly if the jaw angle implants created any vertical lengthening.

While I don’t have the advantage of knowing what your face looks like and an appreciation of skeletal anatomy, I can make some general comments. Removal of porex jaw angle implants is difficult but far from impossible. I have removed such implants numerous times. The question is how best to replace them. There is obviously a reason you had them placed initially whether it was for angle definition, widening or vertical lengthening. Such desired changes would be important to know. It does not appear that standard jaw angle implants may suffice. Custom jaw angle or jawline implants are made off of a 3-D skeletal model. They can be made in any shape and size based on needs and are fabricated out of silicone not porex. Placing the new jaw angle implants is no more difficult than the insertion of the initial jaw angle implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to know if it is possible to have two procedures done at the same time. I want my ears tucked and a mini face lift or a limited lift done. Thank you.

A: Both an ear pinning (otoplasty) and a facelift can be done at the same time under certain cirucmstances. The key to whether these can be performed together is what type of otoplasty and what type of facelift is being planned. In a traditional full facelift there is an incision along the back crease of the ear. This would be lower than the incision traditionally used for an otoplasty which is higher up on the back of the ear. Many plastic surgeons may justifiably feel uncomfortable having two paralleling incisions along the back of the ear due to intervening skin survival concerns. So an otoplasty may not be recommended at the same as a full facelift. In a limited or mini-facelift, the incision on the back of the ear is more limited or not used at all. So an otoplasty can always be performed at the same time as a mini-facelift.

When an otoplasty is done with a facelift there will be some greater and more persistent swelling of the ear but this is an eventual self-solving issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for the longest time I have had my heart set on rhinoplasty but didn’t want to go through a big operation. However I have recently learned that a much less complicated procedure can be preformed that involves reshaping of the nasal tip. (tip-plasty) I was wondering whether or not you feel as though tip plasty would be to my benefit or if you feel as though I should undergo full rhinoplasty. The only aspect of my nose that I have ever had an issue with is that the tip appears too bulbous from the front and 3/4 side view. I also feel as though it protrudes slightly too far from my face. I tried taking some high definition photos, but they would not upload so I had to use webcam photos. the frontal photo is extremely bright however it was the only way to show the definition of my nose from the front.

A: Rhinoplasty is very much like many other aesthetic facial operations, they are numerous versions in magnitude that are used based on the problem being treated. Simplistically, rhinoplasty can be thought of as either a full rhinoplasty or a tip rhinoplasty. The difference between the two is that a full rhinoplasty includes significant changes in the bridge of the nose and will always involve osteotomies or breaking of the nasal bones. Tip rhinoplasty usually does not include much internal work such as septal straightening and turbinate reduction. While there are many cross-overs between these two basic rhinoplasties, depending on patient need and desires, this is a very basic way to view them. More tip rhinoplasties are done in revisional surgery than in primary rhinoplasty.

While your tip is large, I would agree that the top portion of your nose looks in better proportion. I think that an isolated tip rhinoplasty would be of great benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m honored that a surgeon of your stature and extensive experience in reconstructive/cosmetic surgery has replied to my posting. My understanding was that “Kryptonite” was the best material to be used for a cranial implant. I also have a burr hole just above one of my eyebrows and I believed “Kryptonite” would be suitable for both the supraorbital implants an the burr hole plug. As you know HA is brittle. Both HA and PMMA lack the osteo-conductivity of Kryptonite so what is the problem with Kryptonite will it be back on the market at some point or is it off the market for good? I hate the idea of having too loose foreign bodies floating on my forehead. Could enough bone be taken from my hip to carve two implants for my eyebrows and the burr hole?  Theres also a crack that extends downwards from the burr hole. What would you put on this crack.? Bone shavings? If access to the burr hole form the endoscopic brow lift of the upper blepharoplasty isn’t good enough, would it b possible to mke an incision in the eyebrow that will be covered by hair? As you can imagine I would like to avoid a coronal incision at all costs although I had one before and didn’t have any problems afterwards. Would this surgery need to performed by a plastic surgeon like yourself an oculoplastic surgeon, or a maxilofacial surgeon? You are not a maxilofacial surgeon, correct?
I thank you in advance for your help. 

A: I believe you have some basic misunderstandings about the various bone cements. Kryptonite is no more osteoconductive or has higher biomechanical properties than its ‘cousins’, the hydroxyapatite cements. Kryptonite is composed of calcium carbonate while hydroxyapatites are composed of calcium phosphates, thus they are very similar. They are not brittle when applied to the bone and do not become loose. I have used them in many patients for cranial defects and for forehead/skull brow augmentation and have never seen any issues with fracture or fragmentation. That is a theoretical concern that has little clinical relevance.

While Kryptonite had the one feature of some degree of injectability, it otherwise has no other biologic or mechanical advantages. It is no longer available, to the best of my knowledge, because the company voluntarily withdrew it from the market for reasons they did not disclose. I would have no idea if it would ever be back on the market. But your case is not a good case for injection anyway due to your prior surgeries and scar.

The best solution to your brow/forehead issues is to re-open your coronal scar, fill the burr hole and cracks with hydroxyapatite cement and build up the brows also with hydroxypatite cement. This would provide the good access to do the procedure properly. This can not be done through an endoscopic approach nor would the scars through the eyebrows turn out very well. I understand your desire to avoid the coronal incision but that can not be avoided and get a good smooth bony result in the desired shape and fill.

Lastly, I am board-certified in both plastic and reconstructive surgery as well as oral and maxillofacial surgeon with a lot of craniofacial experience since you asked.

Dr. Barry Eppley

Indiana;polis, Indiana