Your Questions

Q: Dr. Eppley, I have one calf that is extremely lager than the other, I always had nice legs and nice calves, I dont have bulging veins, but because I am very fair in complexion, my veins were very visible, so i had the vein injected by a podiatrist . ever since that my left calf has progressively gotten bigger. Please let me know if I can get plastic surgery to reduce this calf as to me it is unsightly, so much i dont want to wear a dress. Help!!!!

A: The first question is how long ago was the vein injected and why did it become bigger after. Calf enlargement is not an expected outcome from sclerotherapy, unless has developed a deep vein thrombosis. If the injection was done recently and you have pain in that calf, then I would recommend that you have it evaluated with an ultrasound to make sure you have not developed a DVT.

From a calf reduction standpoint, there are only two approaches. Either reduce the fat around the calf via small cannula liposuction or muscle reduction. Muscle reduction can be done by Botox injections or denervation but there are considerable costs and some surgical risks with either approach. Liposuction contouring is the simplest and whether that would be effective depends on how much subcutaneous fat exists around the calf area. At a minimum I at least need to see a picture of calfs to determine if that is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have mandibular angle implants but they are just slightly too large and I would like to get them shaved or switched for a slightly smaller pair. 1.) How difficult is the process of shaving them down? 2.) Is the recovery time just as bad as when they were first placed? 3.) Do you recommend shaving them down or switching them out for a smaller pair? Thank you in advance for your response.

A: Modification of jaw angle implant size is certainly easier than the first procedure. This is because the submuscular/subperiosteal pockets have already been made. This is what causes the real trauma and swelling from their original placement. While there will be some swelling the second time around, it will not be as bad as the first. Whether you modify in size or get new jaw angle implants depends on what type of implant was placed (silicone vs medpor) and what is the dimension that you want changed. If it is a silicone implant, I would just replace it with a smaller size as their cost is very low. If they are porous polyethylene (Medpor), I would shave down the existing implants because their cost replacement is substantially higher and they are easy to shave down after they have been implanted for awhile. (get softer with hydration)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I would like to know if I am a candidate for short scar upper arm lift. I had liposuction of the upper arms done 1 1/2 years ago. Since then, my upper arms sag moderately. Thank you

A: Without seeing pictures of your arms, I can only conjecture as to the utility of a short scar armlift in your case. But having had liposuction previously with ‘moderate’ sagging now present, you may well be a candiddate. It depends on exactly where the greatest amount of sagging skin is. The closer it is to your armpit or upper half of the arm, the more likely a limited armlift may be of benefit. It will result in no improvement near the elbow or lower half of the arm.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years).  I also unfortunately had a small amount of buccal fat removed when I was younger.  That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt).  What do you feel is the best way of treating this fat loss?  I’m not really interested in an implant due to cost and I really am interested in restoring volume.  I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view.  I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV).  I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.

A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to change the look of my breasts. I don’t mind having small breasts but I just don’t like the sag. Do you think a  breast lift alone will give me a good result? What are the benefits of implants with a lift? Is the combination better than a lift alone?

A: Your breast sagging and your questions about how to improve them are fairly classic. Your dilemma is not new and it can be hard to figure out what exactly to do. So let me break down into the structural problems. In sagging breasts, there are three elements to them that bother women. First is the lack of upper pole fullness. While a lift may make some immediate improvement, it will not be sustained. This is what implants are used for to create some permanent upper pole fullness. The next issue is the low nipple position that is either pointing forward but low on the breast mound or is pointing downward to the floor. This is what a lift does best, reposition the nipple back up higher and in a more centric position on the breast mound. Lastly, is the bottoming out of the lower breast tissue that hands over the lower breast fold. This also is what a lift helps with by removing skin and tightening the tissues on the lower pole.

This being said, I find in many cases that a breast lift alone can be disappointing particularly in the thin-skinned small breasted patient. It really requires an implant to create sustained upper pole fullness and some upward movement of the breast

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation surgery done over a week ago and now that major swelling has subsided I’m noticing that my implants are way too big, they make my face look round, like a watermelon, and not long and squared like I wanted them to. My question is: can the implant be taken out, reshaped and placed back in? Do you recommend this or should new implants be ordered? Will the revision surgery have the same amount of swelling/downtime as the intial one? Thank you so much for taking the time to answer my questions.

A: Quite frankly, if I have heard these same concerns from one male patient who has had jaw angle implants, I have heard it from the last fifty. You are jumping the gun in trying to determine just one week out form surgery what the results will be. Jaw angle implants cause, by far, the largest amount of swelling of any of the facial implants. Patients generally swell up like a balloon and don’t even start to look human again until three weeks after surgery when maybe 50% of the swelling has subsided. I would not even try to judge the results obtained by these implants until at least six weeks after surgery…three months is even better. Swelling aside, there are numerous other factors which control the shape of the jaw angle afterwards including the original jaw angle deformity and what style of jaw angle implants were used. Size of the implants is one issue but style of the implant and where on the bone they were placed and how they were  secured is even more important. Patience is the key for now. It is just as ‘easy’ later to adjust or switch out the implants at six weeks or three months as it is now. You will only benefit by patient and more healing time to make the right decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been fighting my insurance company since last year due to a yeast infection under the pannus of my stomach. The insurance denied the surgery, saying it was cosmetic, but recently these huge purple marks have appeared and are very thin. A nurse friend said they feel like a blister about to pop and are concave. However, these marks keep spreading across the pannus. My question to you, is, would you, or do you know of a surgeon that would be willing to use me as a teaching subject and take me on as a case study and do the surgery as pro bono? I have had this yeast infection for 7 years and now I am at a standstill. Any advice you could offer would be more then generous. Thank you so much for your time.

A: Battling insurance companies to get coverage for abdominal panniculectomies is standard and the denials and appeals can go on for years. But this is fight you must continue and eventually you should win because you have a real medical necessity condition that justifies an abdominal panniculectomy. It is also a fight you must continue because you are not going to find a plastic surgeon to do it at their own expense. There are also numerous other expenses of surgery (OR, anesthesia, etc) that must be paid that go way beyond whatever a surgeon’s fee is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have decided that I would like to have my cleft lip scar and nose asymmetry repaired. Besides the surgeries for primary repair as a child, I have never considered surgery, so I have no experience in what to look for, how to choose the right surgeon, etc. I was very impressed by your website and the way it explains things. I am very serious about having this procedure done, I just need to figure out the logistics with scheduling, recovery time, costs involved, etc. Please let me know what my next steps should be. Thank you very much.

A: Even with the best primary cleft lip and nose repair as an infant, growth and ongoing facial development of the scarred area will result in lip and nose asymmetries. Most of these secondary deformities are quite classic and include vermilion notching, a vermilion-cutaneous mismatch, wide philtral scarring of the lip and tip asymmetry with nostril slumping and widening of the nose. As an adult, the best nose repair comes from a complete septorhinoplasty with cartilage grafting and a cleft lip revision. These usually can be done during the same surgery. Recovery largely revolves around the nose and includes the wearing of a nasal splint for a week after surgery. You should be back to work within 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to remove excess fat in the pubic and labia area in order to wear pants and bathing suit more comfortably. It is terribly embarrassing when you have  this puffiness sticking out in your clothes. I am not overly fat but my pubic area sticks out further than my stomach. What can be done to reduce this area? I have attached a front and side picture for you to see how big it is. Also I would like to know if I qualify for military discount since my husband is a retired Air Force veteran of Gulf War I and my son is active duty Air Force currently.

A: Based on your pictures, you are an excellent candidate for suprapubic mound liposuction. Fat removal in this area can make it quite flat and is a simple and highly successful contouring procedure of a small area. It can be performed under IV sedation as an outpatient procedure. There will be some mild swelling and bruising and it will take about 3 weeks before all goes down and you are in the benefits phase of the procedure. Because of your husband and son, you most certainly would qualify for a discount for the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very small upper lip which is substantially smaller than my lower lip. I have had several consultations and the recommendations have ranged from injectable fillers, implants to a lip lift.  I am confused by these different recommendations as there doesn’t appear to be a consensus as to the best thing to do. I have attached a picture of my lips for you to see  and give me your recommendation.

A:  As you have discovered there is a variety of lip enhancement procedures that approach making the lips more attractive in a variety of ways. In the end, they all have the same objective, making the vermilion of the lips more pronounced. (increased vertical height and fuller) Think of these procedures as minimally-invasive (non-surgical) to surgical. As a general rule, most patients should always start with injectable fillers because this treatment is the simplest and is completely reversible. What this tells you is whether the existing size of your vermilion can be adequately inflated to achieve the look you want. If it does, then you can ponder whether fat injections or implants may be a better long-term solution. If expanding the existing vermilion is inadequate or produces an undesired look (duck lips), then the location of the vermilion needs to be removed. This is where vermilion advancements and lip lifts have a role to change the vermilion-cutaneous junction and the amount of lip skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First I must say I’m very impressed with your forehead contouring method and I think I come to the right place for my procedure. I am an Asian male who had goretex custom implants placed for brow bone augmentation via a bicoronal incision and fixed with screws. From beginning I was unsatisfied with the result. It gave me extreme brow ptosis with a paralyzed left eyebrow that interferes with my vision. I can not raise my left eyebrow at all. The paralyzed left eyebrow seems like it is caused by implant placement which is placed slightly higher than the right eyebrow. I know because I can feel it. The brow ptosis dramatically changed my youthful eyes shape and made me like an old tired man. I have to keep raising my eyebrow muscles constantly everytime I meet people to make my face look ‘normal’. It has been three years since this surgery and I don’t want to look this way anymore. Now I’m considering brow lift to help my issue. Am I good candidate? What is the best brow lift method to address my complex issue? I tried to avoid bicoronal incision again because it left me with 1 cm width scar ear to ear with no hair growth at all in that area. I even want this ‘bald’ scar removed if possible. Can this brow lift method change my youthful eyes shape back like before?

A:  To lift your brows now, the only option would be to re-use your bicoronal incision. The good news is that the scar needs to be excised anyway to obtain a substantial narrowing of it.  That scar is unacceptable. That would work in helping with the browlift since the amount of brow movement upward should be roughly the same amount as the width of the scar that needs to be removed. I believe this will be successful. Whether it will get the brows elevated as much as you demonstrate with your hands may be overly optimistic but much improvement should be obtained.

As an aside, I suspect your left eyebrow paralysis is the result of an injury to the frontal nerve branch of the facial nerve on that side from the raising of the bicoronal forehead flap. It would be unlikely that the eyebrow doesn’t elevate because it is ‘stuck’ on the brow bone implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 26 years old and have a very flat midface. I would like to do something that will give my midface more projection but I don’t know what is the best thing to do. I read that some doctors use implants while other recommend injectable fillers. I have been through orthodontics to correct my crossbite and it is now perfect. But my face is still pushed in and unattractive with deep nasolabial folds. What do you recommend?

A: By description and as evidenced by your orthodontic treatment, you likely have some amount of natural midface retrusion with a corrected Class III malocclusion. This would indicate a more panfacial or significant midface deficiency of which injectable fillers would be a poor treatment choice. It would take a fair amount of filler volume to achieve a visible improvement not to mention the need for repeated treatments, provided a good aesthetic change could be achieved. There are a variety of facial implant options which can provide both improved midface projection and a permanent result. Malar, submalar, paranasal, premaxillary and infraorbital rim implants are all potential options for augmentation depending upon the amount and location of the midface retrusion. Most patients do well with combined malar and paranasal implants. However the malar deficicency usually has an infraorbital component as well. Similarly, the nasal base deficiency may include a more extensive premaxillary retrusion and not just the lateral pyriform aperture areas. A good eye is needed to determine the type of implant styles that would best treat any patient’s specific concave facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a condition known as facial lipoatrophy. From what I have read it is type III or IV based on how my face looks. I am 24  years old and have had this look since I was a teenager. It makes me look older than I really am and I am concerned if I look this way now what I will look like in 10 or 20 years. I have high cheekbones but they are very skeletal-looking with indentations beneath them with loose skin sitting atop them. What type of surgery will make my face look more normal?

A:  The look of facial lipoatrophy is easily identifiable with loss of some or nearly all subcutaneous and buccal fat over the central portion of the face. Surgery must incorporate both hard and soft tissue augmentation since the problem extends over both bone-supported and non-bone supported facial areas. One successful treatment strategy is a combination of submalar implants to fill out the upper submalar triangle and fat injections for the lower submalar triangle and the sides of the face. Temporal implants can also be used for the always present temporal hollowing which is often overlooked in the treatment of facial lipoatrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could my prominent, asymmetrical eyes be corrected with fillers? A nurse told me that the bones in one eye socket are further apart causing that eye to be able to stick out further. Could they be made even and the bulging eliminated? They are quite “bug eyed” to me which is just genetic. All the women in my family have these eyes. Also, the wrinkles beneath my lower lid when I smile– will the increased volume in that area from the filler eliminate them? Will it also correct the dark skin/shadow under my eye?  I think they really age my face. But I think it’s lack of volume that causes it.  How much would something like this cost in total? Do u use Restylane for this? I really appreciate your time.

A: In looking at your pictures, injectable fillers under the eyes is NOT going to correct you eye concerns. What you have is what is known as pseudoptosis. The eyes bulge out, not because they are too far forward, but because the bone around them (orbital rims) is recessive or deficient. You are not going to lift up the lower eyelid by placing injectable fillers underneath it, that simply will not work. What you need is to have the orbital rims built up with an implant material. For the lower eyelids this would be infraorbital rim implants. For the upper eye area, this would be brow bone augmentation. Understand that the problem is a bone deficiency of which it requires surgical augmentation not injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost weight and have an apron of loose skin that hangs over, plus some fat at my waist that I would love to not have to look at anymore. I have looked at your gallery and have seen a couple of pictures that are very close to my condition, and like the after photos. I would be very happy to look like that. I am 60 years young and still have a lot of living to do. I am very healthy with only a thyroid condition that I take a small dosage of synthroid to correct.

A: Your age of 60 is certainly not a limiting factor in having tummy tuck surgery. As long as you are healthy and have no restrictive medical conditions, which it appears you are, there is no reason not to enjoy the outcome of removal of an overhanging abdominal pannus. Such a removal can be very liberating and improves not only your clothing options and hygiene but your self-image as well. Tummy tuck surgery is performed as an outpatient surgery under general anesthesia. The biggest issue in after surgery recovery is that you will have a drain for 7 to 10 days afterwards. This is more of a nuisance than anything else as you can move about and shower normally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions concerning adding implants to the top of the head. How thick can the implant be at most in your opinion? How is PMMA implants fixed to the top of the skull? Is there any risk of getting loose later and cause infection? Will it thin the skin?Thanks in advance.

A: The thickness of any skull augmentation that can be achieved is directly related to how much the scalp can expand over it. Short of a first-stage tissue expansion procedure, most scalps can stretch 5 to 7mms and have a tension free skin closure. Once you get anything over 10mm, a tension-free scalp closure may become more difficult. Anything cranial implant is secured by small titanium screws through a ‘rebar method’ when it comes to cranioplasty materials that are applied initially as liquid-powder or putty mixtures that then set up. Looseness or infection are two potential complications that I have not seen. There is always some slight tissue thinning around any body implant that expands the overlying tissue. But the scalp is very thick and any tissue thinning over a long time does not affect the skin or the hair follicles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a little nervous about a cranial reshaping/augmentation procedure so if you don’t mind I have some questions regarding it. Does this type of surgery come with a high risk of complications/ what are the complications? From the location of my indentation can you give me a general idea of how big and where the location of the scar would be? How long would an open approach surgery take to correct my indentation/ how long would recover time take? How much would this surgery cost roughly? If my research is correct I understand their are different methods/ materials that can be used with an open approach can you explain them? and the pros/cons of them? What method would you recommend?

A: In answer to your questions. This is not a high-risk procedure. There are no major complications that I have ever seen. The complications are of the aesthetic nature, meaning how does it look, is it smooth, etc. You need access to both sides of the skull. There fore the incision would be bicoronal, meaning it would go across the top of the head just about from one ear to the other. Surgical time for this procedure is 2 hours. Your recovery would be very quick, so swelling but no significant pain and no real restrictions after surgery other than strenuous physical contact. That information will be passed along by my assistant. The other decisions/options about an open approach is the choice of cranioplasty material. With large surface area to be covered like your cranial indentations, the PMMA (acrylic) is the most affordable. I am not sure what you mean by method. This would be an open cranioplasty with midline bone reduction and build up of the deficient sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can a direct vertical incision be used for women with vertical bands of turkey wattle?  I had a facelift 20 years ago when the platysma was tightened and there is no flesh left behind my ears (very bony and thin).  If it were performed as an “H” on its side, then it may be confined to under the chin and not be so visible on the actual neck?

A: The answer is that direct necklifts can be done just as  easily in women as in men. However the design to which you refer to is known as a submentoplasty where the scar is completely under the chin and not onto the neck. Direct necklifts, by definition, involve a vertical cutout of skin and fat down the center of the neck. But the cutout pattern always is like an H its side with the final incision closure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and i have just one concern about my eyes showing a bit too much sclera and lack of support of lower eye lids…i had fillers injected but I must say that the improvemnet was mild to non existant and did little for the scleral show even if the lateral volume was improved. Also fillers tend to be pulled by gravity and the infraorbital fillers the shifts and becomes more of a feminized cheek implant. I was imagining that infraorbital rims will be more precise and long lasting. Also I was wondering if the rim itself will push the lower eyelid enough to show les sclera or if it would be better to tighten up the sides as well. I always found that I look much better when I squint slightly which makes me believe this is what i need…how natural doesthis procedure look? is it a spectacular change? Do rim implants shift as easily as jaw angles? Thank you

A: The position of the lower eyelid is affected by many factors but one of the most significant is the amount of bony support from the lower orbital rim. Adding permanent volume through an implant is a logical choice. The amount of volume added is dependent on the style and size of the infraorbital rim implant. Regardless of the implant, tightening the lower lid through a lateral canthoplasty is always advised/done. Moving the level of the lower eyelid up is never an easy task but the combination of infraorbital rim implants and canthoplasties gives the best chance for that to occur. Since I always screw the orbital rim implants in, like all facial implants, I have never seen implant shifting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a midface deficiency which is causing the skin of my midface to sag alot causing it to look pigmented, I have been told I am more suitable for orbital rim implants (after many consultations for standard cheekbone implants) but it seem a subtle implant is all that can be used due to my skin not being very hefty. What I want to know is how far around from the nasion area around to the malar lateral area does the implant reach? Will it fill out the area on outer corner of eyes where a normal persons cheekbones would normally be located? I generally have good projection on the sides of my head, but I have developed a fat face appearance and I’m only 24, this is giving a pigmented look to the unsupported skin. It’s like I’ve lost a lot of weight which I haven’t as I’m only 150lbs.I have been told I could go with fat transfer after implants if I wanted a more drastic change later on down the road. Will subtle rim implants be enough to lift the sagging skin as it feels like there is a lot? My face has no angles like it used to and has become very doughy. I’m depressed over this as I simply don’t know what to do.

A: While I will have to see pictures of you, I can make some general comments in regards to infraorbital-malar implants. There are numerous styles and designs of orbital rim, malar and combined infraorbital-malar implants. Some do reach the whole way from the medial orbital rim around and onto the malar region and up on the lateral orbital rim. How much midfacial tissue lifting these implant styles do is limited. Some malar tissue elevation is obtained but more significant amounts will likely need some form of a midface lift done concurrently with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant that was placed 35 yrs ago when I was 18.  My dentist tells me that the bone has eroded behind the implant and that some teeth that are now moving in that area.  It is a silicone implant. I know I have to get it removed but can I have a new chin implant or is that that? My surgeon said to take it out and consider a new implant when it is healed but I do not want another silicone implant and there’s a lot of info on the internet stating they too have had serious bone problems with silicone chin implants. Is this common? Thank you.

A: Never confuse passive implant settling with active erosion. Chin implants do not actively erode bone, they merely respond over time to the pressure of the overlying soft tissue and something has to give. This phenomenon can particularly be seen when the implant sits too high over the softer and thinner bone cortices in front of the roots of the mandibular incisor teeth. Obviously you have an old implant that is positioned too high, which is why it is closer to the tooth roots. A properly positioned chin implant sits down on the basal bone, some distance away from the level of the tooth roots. You simply could have the implant removed, an allogeneic bone graft placed into the cortical defect and a new chin implant placed in a lower proper position if desired. Whether that should be a silicone or Medpor implant is a matter of debate. I suspect the implant is small and, because it is positioned too high, probably has little actual influence on the horizontal projection of the chin.
>
> What has happened is a natural long-term process that is not reflective of pathology or some mysterious substance leeching from the implant causing this bone/radiographic reaction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, thank you for doing the imaging. Regarding my chin and jaw I had something different in mind, I wanted something more defined and v- shaped for my jawline. Some implant that would probably wrap around my whole jaw and give me a more defined look. I’ve attached a picture of Matt Bomer to illustrate what I exactly have in mind and please tell me if I’m being realistic or not. If getting such a structure is a bigger job and you feel that a custom implant is more suitable, I’m more than fine with that. Too be honest doctor, I want to have everything perfect even its going to cost me more. Regarding the cheek bones? Do think augmentation is suitable for me or not?

A: The purpose of computer imaging is to transition the talking to a visual interpretation. It is a starting point for refining goals. What you have seen and do not like is what off-the-shelf chin and jaw angle implants do. They are fine for many patients but will not give a smooth jawline connection between the two. Only a custom wrap-around jawline design can do that.

I think using the picture of Matt Bomer is helping to define your objectives but you can never have his exact jawline because his facial tissues are thinner (less fat). Therefore, his jawbone anatomy is very well revealed including the angular flare. Your facial tissues are a bit thicker so you can end up somewhere between where you are now and his look.

In regards to the cheeks, I think they would also be helpful in achieving your desired facial look. I have done additional imaging based on these concepts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a jaw and/or chin augmentation procedure. I believe my chin would look better if increased length-wise, but I am unsure if a chin implant is able to achieve this (as opposed to the bone shift procedure). I am attaching some pictures so you can see my face from the front and side. I apologize about the poor lighting–I spent several months cultivating a beard, and these are the only pictures I have without the facial hair.

A:I have taken a look at your photos and feel that you are correct…your chin is deficient both horizontally and vertically. Your facial hair shows the vertical increase already and perhaps, consciously or subconsciously, this is why you grown it.  Either a chin implant or a chin osteotomy can create vertical chin lengthening but it depends on what you want the overall dimensions of the chin to be. A chin osteotomy will lengthen the chin but will also narrow it in width by doing so. (unless a simultaneously placed thin extended implant is placed along the bony margin at the same time) A chin implant can make the chin longer and wider (more square) but it would have to be a custom implant. There are no off-the-shelf chin implants that create that effect.

Q: Dr. Eppley,  I an a 45 year old female with a total avulsion of my left ear with skin graphing to cover the skin loss.  My car accident was twenty years ago and the ear was found at the accident, however it was macerated and nonusable, as well as the tissue behind the ear.  As I am getting older I am having numerous eye issues with severe dry eye syndrome and having to wear glasses and this is quite difficult with missing an ear.  Unlike the lady in this segment, I do not have an ear lobe and no extra skin.  I would even be happy with some sort of way to hold up my glasses.  I wanted to know if there was anything that could be done to help me function normally to wear my glasses.  Look forward to your response.  Thank You.

A: I think there are two approaches to your ear reconstruction depending upon exactly what you want the final outcome to be. The skin graft in place precludes any attempt at making and inserting a cartilage framework through a traditional microtia reconstruction approach. This requires supple skin that can either be elevated or tissue expanded. The standard approach would be the insertion of endosseous implants followed by the attachment of a prosthetic ear. This provides good prosthetic retention and should easily hold up a pair of glasses. A secondary approach would be to create a shelf of cartilage above the skin graft or at its edge onto which glasses could rest. This will not create an ear but more like just the upper ¼ or 1/3 of it. Whether this is possible will require reviewing a picture of what the ear site looks like and the exact location of the skin graft.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I had a terrible broken nose when I was 10. The resulting deviated septum (and septal perforation) caused terrible nosebleeds throughout adulthood, but the structure of my nose looked good visibly. I had a septoplasty to correct the deviation in 2005 and hopefully stop the horrific nosebleeds. The results were terrible. My septum (which I was told before surgery had a pinhole in it) collapsed and I now have a saddle deformity and the tip is much wider and bulbous. I am told the hole in the septum is about the size of a pinky fingernail. Functionally, it is average. The septum is straight but crust builds up in the perforation and usually blocks one side of my breathing. Aesthetically, I am very disappointed. I still have very bad nosebleeds, but not quite as severe. How experienced are you with this procedure? About how many have you done? Successful results? If you think you may be able to help correct this, I would like to set up a consult. Thanks!

A: You appear to have two separate but challenging nasal issues, that of a septal perforation and a saddle nose deformity from collapse. This combination nasal problem is not rare and loss of septal support is the main reason for a saddle nose problem. The saddle nose deformity is best corrected through an open rhinoplasty approach using a rib cartilage graft to build back up the dorsal line and provide some tip projection and support. That is a very effective and successful procedure. Septal perforation repair, particularly if it is large, is a very difficult problem and has a high rate of failure. This is due to the lack of good mucosal tissue to move and provide a vascularized lining coverage on both sides of the nose. If it is a perforation bigger than 10mm in diameter, it may prove to be quite difficult to try and fix and you may be better served to leave that part of your nasal problem alone.

Q: Dr. Eppley, can breast implants be injured during sex? While having sex with my husband he leaned on my breast and it caused some immediate pain. For the past few days now, I have had lingering pain although it has gotten better. That breast also feels a little harder now. Could I have a breast implant rupture? I had silicone implants placed three years ago.

A: Your question is actually a common one and let me provide an overall explanation. The shell or bag of a breast implant is made of a very flexible but strong silicone elastomer material. It is designed knowing full well that it will regularly be exposed to a compressive crushing force…known as mammograms. Any woman that has ever had a mammogram can testify to the fact that their breast is really squashed between two paddles to do a mammogram. Millions of breast implants are exposed to lots of mammograms every year in the U.S. and around the world and there is no evidence that they induce rupture unless the implant shell has already been weakened. So it is highly unlikely that rupture of breast implants can occur as a result of sexual activity. It takes a high energy force to rupture a breast implant such as might occur from an automobile accident or other traumatic injury. What you are likely feeling is a mild bruise around the implant capsule which should go away in a few weeks. If in doubt, an MRI or a high definition ultrasound will be needed to answer the breast implant rupture question conclusively.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can you tell me if placing a temporal implant about 9mm thick under the temporal fascia, does this cause the eyes to appear smaller? Like does it pull the skin more to the temporal area and away from the eyes? It would be helpful for me to know, thanks.

A: That is an interesting question and one that I have never heard before. Temporal implants may push the skin in the temporal fossa outward but they do not cause any pull on the eyelid skin or the corner of the eye. Thus, temporal augmentation would not have any direct effect on the appearance of the eye. Whether it may secondarily cause the eye to appear smaller because of a more flat or convex temporal region is possible but not a complaint that has ever been voiced to me nor one that I have seen.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting paranasal/premaxillary implant to build out my nose area. I have a few questions/concerns with these implants.

1.  Will the implants cause my nostrils to show more, less or the same from front and side views? I don’t want a pig snout.  I think my nostrils show too much already since my rhinoplasty so I don’t want it to get worse. 

2.  Will the implants cause my upper teeth to show less?

3.  Approximately how long will my face be swollen and bruised?

4.  Will the implant show bulky or any bulges under my skin?

5.  Can you fix the area under my lower lip between the chin and lower lip to not look like it is pushed in?  It’s hard to tell on the pictures, but having some teeth removed prior to orthodontics has made my lower lip look pushed in and my chin come down with smiling which you said you could fix.  Is there a filler or implant I can use to get that projection instead of the dent/depression I have under my lower lip? 

A: In answer to your questions about parasnasal or premaxillary implants,

1) I don’t believe it will change your nostrils to any significant degree. I am assuming when you mean nostril show that you mean the tip of the nose would move upward thus exposing more nostril show. This will not happen.

2) There should be no impact on your upper tooth show. In other words, it doesn’t lift or shorten the upper lip.

3) There will be some swelling that show largely be gone by three weeks after surgery. I have never seen any bruising with paranasal or premaxillary implants.

4) The implant will not have any visible edges. The nasal base/midfacial tissues are too think to ever show an implant edge. 

5) I believe you are referring to the depth of what is known as the labiomental sulcus or crease, which is the groove between the lower lip and chin. This is best softened in depth by the placement of a subcutaneous implant (Permalip) made just for that type of augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been doing a lot of research to find out ways to fix an indentation I have on the left side of my skull and I read on your website about a procedure that you do using kryptonite bone cement to reshape irregularities in the skull. These irregularities were caused from birth. I would like to send you some pictures to see if my problem can be corrected using this method. Also other then overcorrection are their any other risks with this type of surgery? Another question I have is does insurance cover it, or is it considered purely cosmetic.

A: Of the available cranioplasty materials, Kryptonite is no longer available for use. The company that produced it has withdrawn it for any further sale currently. Therefore, there is no longer any injectable approach to skull augmentation or indentation correction. An open cranioplasty incision would be needed to place any of the other cranioplasty materials. Other than the scar, minor contour issues remain as the only risk. Skull reshaping or indentation correction is not a procedure that would be covered by insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want to have a strong chin and don’t want to narrow it, I think from side view my chin is receding and weak. Please take a look at my photos and give me some advices, what should I do with my chin , I want to bring it forward as much as possible and in your website I see amazing before and after photos, your work is very artistic. If I were in the US I would have flown to your clinic today but unfortunately I am far away and I can’t afford to come for a surgery. If you know someone in overseas who you think his work is excellent please recommend me so that I perform my chin surgery some months later. I may refer to any doctor based on your recommendation because I have trust and confidence in you. You know finding a good doctor is very important.

A: Based on your photos, your chin deficiency is very mild and you already have good chin width in the frontal view. I would recommend an implant as opposed to an osteotomy. This is the most assured way of getting better horizontal as well as transverse width increase. An osteotomy will bring your chin forward but will also make it more narrow as well. Otherwise, I have no surgeon recommendations for you in your part of the world as I simply do not know any surgeons either professionally or personally.

Dr. Barry Eppley

Indianapolis, Indiana